My aunt Eva came home after my cousin’s debut party scratching her legs and complaining of extreme itching. She hiked up her pants and scratched her legs frantically, all the while asking herself and her husband what she could have eaten to trigger the itching.

Tita Eva is diabetic. I remember her when I was younger with white, creamy complexion devoid of ugly marks. Now, her legs are all covered with red to brown spots – pigmentations, which doctors call diabetic dermopathy.

Pigmented spots in the legs are the main signs of diabetic dermopathy, a complication brought about by long-standing diabetes (having diabetes for 10 to 20 years). It is a skin disorder that most commonly occurs on the shins of people with diabetes, and is characterized by light brown or reddish, oval or round, slightly indented scaly patches and small bumps that often become pigmented and ulcerated, and eventually result in scars.

Diabetic dermopathy is just one of many diabetes-related skin problems. Medical experts report that one out of every three diabetics will have some skin disorder related to their disease. By understanding why diabetics are prone to such skin problems and learning how to properly care for your skin, you can help keep yourself safe and healthy.

Diabetic skin problems
“People with diabetes mellitus suffer a variety of skin problems that range from bacterial and fungal skin infections, to skin changes associated with diabetes like shin spots, necrobiosis lipoidica and acanthosis nigricans, to skin problems that are part of complications of diabetes like skin ulcers, to uncommon allergies to diabetes medications,” said endocrinologist Dr. Gabriel V. Jasul, Jr.

These skin problems may vary from one person to another and not every diabetic develops these skin problems, added Dr. Jasul, who is chairman of the Advocacy Committee of the Philippine Society of Endocrinology and Metabolism (PSEM). “Diabetics have skin problems that may be directly or indirectly related to their disease,” said dermatologist Dr. Ma. Lorna Fernandez-Frez, immediate past president of the Philippine Dermatological Society (PDS). Although some skin problems reflect current poorly controlled blood sugar levels, many skin conditions are related to long-standing diabetes, added Dr. Frez. Some of the most common skin problems associated with diabetes can be classified as either bacterial or fungal infections.

Bacterial
A bacteria called Staphylococcus aureus, a common cause for skin infections even in non-diabetics,may invade hair follicles and cause folliculitis (inflamed hair follicles), boils or abscesses, explained Dr. Frez. If untreated, infections caused by bacteria may become florid or chronic and recurrent. For example, abscesses or boils and cellulitis (a large red patch on the skin usually on the leg, and is usually caused by Staphylococcus aureus or B- hemolytic Streptococci) may spread to the blood circulation. This condition is called sepsis or septicemia, which may put a diabetic at risk for coma necessitating intensive treatment, Dr. Frez said.

Fungal
Moist areas of the skin may serve as breeding ground for fungal organisms that may cause red itchy rashes underneath the breasts in women, armpits, groin, and in between fingers and toes. Fungal organisms may likewise cause infections in the skin around the nails as well as the nails themselves. The genitals of both women and men may likewise be affected, especially in uncircumcised men where it may cause a lot of itching. In women, vaginal infection is usually associated with some discharge.
Impaired function of large and small blood vessels are also reflected on the skin, said Dr. Frez. “Thickening of large vessels supplying the skin may cause paleness, coldness, loss of hair and a shiny appearance especially on the toes,” she added.

Dr. Frez went on to say that in severe cases where blood supply is totally compromised because of impaired function of the blood vessels, death of skin tissue or gangrene, which appears as black discoloration of the skin, may ensue. In these cases, the skin may either remain dry or become wet and oozing due to secondary bacterial infection. Total death of skin tissue necessitates amputation of the affected limb or digit, she explained.

“Numbness of the hand and feet signifies impaired nerve function in these areas,” according to Dr. Frez. She further elaborated that the feet is specifically prone to various skin infections because it is constantly under pressure from bearing ourweight and friction due to the use of footwear. Constant unsensed friction in the feet will cause the formation of calluses which eventually break down and produce non-healing ulcers. Poor blood supply to the affected area affects and slows down healing of wounds, she said.

“Aside from leg ulcers, the legs of a diabetic may be predisposed to developing skin lesions — most commonly, brown patches of discoloration. Some patients also present with thickening of the skin especially around fingers and occasionally impair joint movement. These two are associated with long¬standing diabetes, signifying impaired small vessel circulation,” explained Dr. Frez.

“People with diabetes can also develop common skin conditions that are seen in those people without diabetes like allergies, itching, sunburn, insect bites, acne, etc.,” Dr. Jasul said.

Causes of diabetic skin problems
Some of the skin changes and problems encountered by diabetics, like impaired wound healing, are directly related to elevated sugar levels and small blood vessel changes particularly with diabetic nerve and vascular complications, said Dr. Jasul. He added that duration of diabetes also plays a role in these skin problems.

However, many skin problems in diabetics do not have clear causes, he explained. He said that even minor skin trauma, as well as dehydration resulting from fluid losses as a cause of high blood sugar levels, ‘may contribute to skin changes.

Altered skin quality among diabetics, to a certain degree, makes them more prone to skin problems. Also, having diabetes for a long time with complications may cause the skin to be more susceptible to injury from minor trauma because of dryness, loss of elasticity, poor circulation, loss of sensation and slower healing, furthered Dr. Jasul. “It then becomes a cycle where diabetes causes skin

changes aggravated by poor diabetes control worsening the skin problems, getting superimposed infections, further making sugar control difficult, and so on,” he said.

Symptoms of diabetic skin problems

According to Dr. Jasul, most skin infections among diabetics will present with minimal symptoms and will only be noted once the infections become quite advanced.

In some cases, fungal infections of the skin, especially among women, can even be the presenting symptom leading to diabetes.
For those with long-standing and far-advanced diabetes, foot infections and skin ulcers are common. Dr. Jasul said that patients with these conditions will have some loss of skin sensation or changes in hair and sweating pattern in the feet. Once the infection is full-blown, the usual signs of infection like pain, swelling, tenderness, redness and fever will be present.

However, Dr. Jasul explained that some of the skin changes in diabetics are asymptomatic and may just be cosmetic in nature. “The so-called diabetic dermopathy or shin spots is an example of this. Shin spots are small discolorations often seen on the shin but are often painless,” he said.

Another skin problem among diabetics, according to Dr. Jasul, is necrobiosis lipoidica, which is characterized by oval plaques, with yellow central portion and elevated, thickened edges often seen in the legs and is often painless. Overweight diabetic patients and some individuals considered at risk for developing diabetes may also experience darkening and thickening of skin folds especially in the nape, armpits and groin – a skin problem called acanthosis nigricans, he said.

Treatment and Prevention

Diabetes complications and poor blood sugar control make treatment of skin problems among diabetics more difficult, particularly skin problems related to infections. Healing, therefore, tends to be slower and may take longer to respond to treatment.

“Adequate control of blood sugar levels is helpful in controlling and preventing some skin infections,” Dr. Frez advised. Dr. Jasul also stressed the importance of good and stable diabetes control, since many of the skin problems in diabetics particularly skin infections, get worse with poor blood sugar control.

To prevent the occurrence of fungal infections, Dr. Frez advised that patients should keep skin, especially body folds, clean and thoroughly dry after bathing. And as much as possible, avoid trauma and other form of injury, she added. Protect the feet at all times by wearing comfortable footwear. A diabetic patient should never walk barefoot. The soles of the feet should be inspected regularly to detect wounds and infections for early diagnosis and treatment. Pedicures should be done professionally, and patients should advise their pedicurist to avoid aggressive moves like removing ingrown toenails. It is also recommended that diabetics use their own instruments when having pedicures to avoid contamination and infections, explained Dr. Frez.

Using lotion regularly can help improve some of the skin changes and prevent the development of some of the mentioned common skin problems among diabetics. Doctors also recommend complete skin examination, giving special attention to the feet, as part of routine diabetes follow-up.

“The recognition that skin is the largest organ of the human body and that it serves as a major protective barrier should make us take care of our skin well,” advised Dr. Jasul. He added that as much as 30 to 70 percent of people with diabetes experience skin problems, and therefore, examination of the skin should be part of daily patient self-care and of regular clinic check-up. Dr. Jasul also advised that skin changes that develop and persist for more than three to five days should merit attention and be shown to a doctor as soon as possible.

Medical societies involved in the care and treatment of diabetes and the skin like the PSEM and the PDS also do their part in helping prevent skin problems among diabetics. As part of the advocacy program of PSEM, Dr. Jasul mentioned that patient information brochures on diabetes mellitus that the PSEM will produce will include modules on different complications of diabetes, including skin problems. Dr. Jasul also disclosed that as part of their research agenda, they are encouraging diabetes research that should focus on prevention and treatment of complications, including giving more attention to skin problems in diabetes, which is a neglected area of investigation.

For their part, Dr. Frez said that although the PDS has no special program addressing the diabetic skin, they have an educational program that is meant to promote healthy skin for all through the proper care of the skin, hair and nails.
Being aware of your skin and the changes that are happening to it is the key to prevention of skin problems. “Patients who are well educated about self-care and prevention will easily notice any early skin changes, which should be seen by their doctor,” said Dr. Jasul. Regular consultation with their doctors will facilitate early treatment, as well as monitoring of response to treatment, he added.

Good diabetes control and treatment of other existing medical problems can prevent skin disorders. Most importantly, loving the skin you are in by taking good care of it is the best way to keep your skin free from any diabetes-related problems.

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