Diabetes mellitus is a common cause of health problems and death, not only in the Philippines but in the whole world. In diabetes, insulin is lacking, either partly or completely, leading to gross defects in glucose (sugar), fat, and protein metabolism. Because of these defects, the organs that are most commonly affected include the heart, blood vessels, nerves, eyes, and the skin. A fasting blood glucose level of 126 mg/dL and above on two separate occasions or a random value of 200 mg/dL and above confirms the diagnosis of diabetes.

Nearly all patients with diabetes have cutaneous (or skin) findings related to their condition. It can either be a direct result of the related metabolic changes such as hyperglycemia (high blood sugar) and hyperlipidemia (high blood cholesterol), or a progressive damage to the blood vessels or immune system.

Skin findings in diabetes
Acanthosis nigricans is the most readily recognized skin manifestation of diabetes. It is the brown to gray-black pigmented thickening of the skin of the neck (sides and back), armpits, groin and folds in the abdomen. The affected skin has a dirty, velvety texture. The back of the neck is the most consistently and severely affected area. Treatment of acanthosis nigricans is generally ineffective; thus, using a whitening soap or cream will not remove it.

Diabetic limited joint mobility (LIM) and scleroderma-like syndrome or cheiroarthropathy is the painless loss of joint mobility or movement. This is because of the tightness and thickening of the skin and connective tissue around the joints of the fingers. The tip of the 5th finger (pinky) is the first one to be involved, which usually progresses to involve all fingers. Larger joints of the elbow, knee, and foot may also be affected.

Scleredema diabeticorum presents with a very slow onset of painless thickening of the skin on the upper back and neck. It may also spread to the face, shoulders and chest. The skin possesses a non pitting, woody, peau d’orange (orange peel) quality.

Eruptive xanthomas are 1- to 4-mm, reddish-yellow papules on the buttocks and extremities (arms and legs). The lesions occur in crops and may join together into plaques over time. Although eruptive xanthomas are generally asymptomatic and therefore not bothersome to the individual, it is usually associated with high levels of triglyceride (more than 1,000 mg/dL) and potentially undiagnosed diabetes.

Bacterial and fungal infections. In diabetic patients, several skin infections occur more commonly with greater severity or with a higher risk for complications.

Among the bacterial infections seen are “strep” (Group B Streptococcus) and “staph” (Group A Staphylococcus) infections, outer ear infection due to Pseudomonas and a deeper skin infection called necrotizing fasciitis caused by Escherichia coli and other bacteria.

Fungal infections are common especially among those with poorly controlled diabetes. We usually see Candidal infections in between finger and toe webs, armpits, groin, vagina, urethra, and angles of the mouth.

Diabetic ulcers. Foot ulcers are seen in 15-25 percent of diabetics, making it a significant problem. Among those with foot ulcers, 14-24 percent will eventually undergo amputation.

Characteristic lesions appear on the lower legs, especially on the shin.

Diabetic dermopathy, which presents as small (1 cm), pink to brown, scar-like patches, occurs more often in patients with an increased duration of diabetes and is more frequent in men. The lesions clear within 1-2 years with very little scarring or lightening of the skin.

Necrobiosis /ipoidica (NL) on the other hand, presents with one to several sharply demarcated yellow-brown thicker patch with purplish irregular borders.

Lesions start as red-brown bumps on the skin, which flatten over time. The center then becomes yellowish and thin so that you can see the blood vessels and pinpoint blood clots underneath. NL can also be seen in ankles, calves, thighs, and feet.

Granuloma annulare are round lesions with small papules surrounding it.

Bullous diabeticorum is a rare skin lesion in diabetes, characterized by abrupt, spontaneous development of blisters on the lower extremities without other demonstrable cause.

Always remember:

• Do not ignore abnormalities found on the skin!
• Skin problems can be controlled if addressed promptly and correctly.
• Regularly check for any rapidly changing, irritated, bizarre looking moles, lumps, warts and other pigmented lesions.

When in doubt about some skin changes or new growths, do not hesitate to consult a PDS-accredited dermatologist.

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