Cutaneous Manifestations of Diabetes Mellitus

1. Cutaneous Manifestations of Diabetes Mellitus Dr Noreen Cowley MD FRCP Consultant Dermatologist

3. Cutaneous No Pathonomonic Skin lesion in Diabetes

4. Cutaneous Manifestations of Diabetes 30% incidence cutaneous disorders ADA 70% during course of illness 15% ulceration

5. Cutaneous Manifestations of Diabetes Hyperglycaemia Neuropathy Impaired host response Microvascular angiopathies with failure of the microcircutation to meet the metabolic requirements of the skin

6. Cutaneous Manifestations of Diabetes • Common disorders that affect non-diabetes • Those classically associated with diabetes / reflect microangiopathy • Lesions indicating poor control • Effect of insulin resistance • Adverse effects of therapy for diabetes • Skin changes as a result complications of diabetes • Other associated autoimmune disorders

7. Cutaneous Manifestations of Diabetes Common disorders that affect non-diabetics Those classically associated with diabetes / reflect microangiopathy Lesions indicating poor control Effect of insulin resistance Adverse effects of therapy for diabetes Skin changes as a result complications of diabetes Other associated autoimmune disorders

8. Skin Infection 20-50% (Type 2) poor glycaemic control Poor micro and macro-circulation Neuropathy Altered immune response Dermatoses “portal of entry”

9. Skin Infection Staphylococcus folliculitis Superficial fungal infection Cellulitis and erysipelas Oral and genital candida Non pathogenic organisms mucormycosis by phycomycetes and anaerobic cellulitis by clostridium species

10. Erythrasma

11. Cutaneous Manifestations of Diabetes Common disorders that affect non-diabetes Those classically associated with diabetes / reflect microangiopathy Lesions indicating poor control Effect of insulin resistance Adverse effects of therapy for diabetes Skin changes as a result complications of diabetes Other associated autoimmune disorders

12. Necrobiosis Lipoidica

13. Necrobiosis Lipoidica

14. Necrobiosis Lipoidica Aetiology Microangiopathy –---collagen degradation with release cytokines from inflammatory cells – destruction collagenous matrix Little evidence correlation retinopathy/nephropathy

15. Necrobiosis Lipoidica 0.3-0.7%

16. Differential Diagnosis

18. Generalized Granuloma Annulare

19. Diabetic Dermopathy “Shin Spots” Shemer et al 40% Men – 50yrs

20. Diabetic Dermopathy Severe microvascular complications Retinopathy,neuropathy,nephropathy Closely linked to glycosylated Hb High risk of accelerated diabetes complications

21. Bullosis Diabeticorum

22. Bullosis Diabeticorum Type 1 Diabetes 0.5% Men Longstanding Disease Peripheral Neuropathy

23. Cutaneous Manifestations of Diabetes Common disorders that affect non-diabetes Those classically associated with diabetes / reflect microangiopathy Lesions indicating poor control Effect of insulin resistance Adverse effects of therapy for diabetes Skin changes as a result complications of diabetes Other associated autoimmune disorders

24. Eruptive Xanthomas

25. Scleredema of Buschke

26. Scleredema of Buschke Type 2 Obese Therapy resistant Cardiovascular Retinopathy

27. Cutaneous Manifestations of Diabetes Common disorders that affect non-diabetes Those classically associated with diabetes / reflect microangiopathy Lesions indicating poor control Effects of insulin resistance Adverse effects of therapy for diabetes Skin changes as a result complications of diabetes Other associated autoimmune disorders

28. Acanthosis Nigricans 8 types Obesity – Acanthosis Nigricans Kahn 1975 association with insulin resistance

29. Acanthosis Nigricans Mechanism? High insulin concentrations stimulate insulin–like growth factor receptors on keratinocytes promoting epidermal cell proliferation

30. HAIR-AN Syndrome • HyperAndrogenism • Insulin Resistance • Acanthosis Nigricans

31. HAIR-AN Syndrome Type A I R Mutation gene that encodes the insulin receptor Tall black young females Severe acanthosis nigricans begins infancy and early childhood Alopecia

32. Cutaneous Manifestations of Diabetes Common disorders that affect non-diabetes Those classically associated with diabetes / reflect microangiopathy Lesions indicating poor control Effect of insulin resistance Adverse effects of therapy for diabetes Skin changes as a result complications of diabetes Other associated autoimmune disorders

33. Auto-Immune Disorders Vitiligo 1-7% in diabetes 0.2-1% non-diabetic

34. Lichen Sclerosis et Atrophicus

35. Lichen Sclerosis et Atrophicus

36. Cutaneous Manifestations of Diabetes Common disorders that affect non-diabetes Those classically associated with diabetes / reflect microangiopathy Lesions indicating poor control Effect of insulin resistance Adverse effects of therapy for diabetes Skin changes as a result complications of diabetes Other associated autoimmune disorders

37. Cutaneous effects of Therapy • Insulin • Oral hypoglycaemic agents Metformin Psoriasiform drug eruption Erythema Multiforme Leucocytoclastic Vasculitis

38. Lipoatrophy/hypertrophy Lipoatrophy Thighs/arms children and young women Lipohypertrophy Males Subcutaneous deposition fat at injection sites Insulin –induced stimulation of adipose tissue growth

39. Cutaneous Manifestations of Diabetes Common disorders that affect non-diabetes Those classically associated with diabetes / reflect microangiopathy Lesions indicating poor control Effect of insulin resistance Adverse effects of therapy for diabetes Skin changes as a result complications of diabetes Other associated autoimmune disorders

40. Perforating Collagenosis

41. Perforating Collagenosis Elimination of focally damaged collagen through the epidermis

42. Necrolytic Migratory Erythema Stomatitis Weight Loss Diabetes Mellitus Glucagon-secreting tumour of the pancreatic islet cells Mechanism? Sustained gluconeogenesis from high glucagon levels leads to amino acid deficiency,epidermal protein deficiency and necrolysis

43. Thankyou Any Questions?