Skin Disorders and Diabetes

Skin Disorders and Diabetes

Also called: Dermatopathy, Diabetic Dermopathy, Dermopathy

Summary

People with diabetes are prone to many skin disorders. These include conditions that affect only diabetic individuals and conditions that occur more frequently or are more serious among diabetes patients.

Diabetic skin conditions include abnormal growths, ulcers, infections and changes in the skin itself. They range from harmless to potentially fatal, from common to rare, from easily cured to complex. Among the serious diseases, early treatment often prevents complications and speeds recovery.

There are many reasons people with diabetes face increased risk of skin problems:

  • Impaired circulation
  • Hyperglycemia (high glucose)
  • Hyperlipemia (high levels of fats in the blood)
  • Suppressed immune system
  • Diabetic neuropathy (nerve damage)
  • High blood pressure

The key to prevention of many types of diabetic skin conditions is regular good hygiene and control of risk factors. Treatments depend on the particular disorder but often include surgical incision or debridement (removal of damaged tissue) and antibiotics, antifungals or other medications.

About skin disorders and diabetes

Skin problems are a common complication of diabetes. As many as one–third of patients with diabetes experience a skin disorder at some point in their lives, according to the American Diabetes Association (ADA). Skin disorders are sometimes the first symptom of diabetes that a patient experiences.

Skin conditions are more dangerous to people with diabetes than to those in the general population. The high levels of glucose (blood sugar) associated with diabetes prevent rapid healing, allowing even minor cuts to progress to serious infections.

Skin disorders associated with diabetes can also be described according to three categories:

  • Rashes, abnormal growths and eruptions
  • Bacterial and fungal infections
  • Abnormal changes in the skin’s structure, thickness or color

People with diabetes also face higher risk of two common and potentially severe kinds of skin ulcer: foot ulcer and pressure ulcer.

Often these disorders can be prevented by caring for the skin and controlling risk factors such as hyperglycemia (high glucose) and high blood pressure.

A program of skin care and hygiene for people with diabetes includes:

  • Rinsing and drying well after washing with a mild soap
  • Using a moisturizer
  • Inspecting the skin daily
  • Informing a physician of problems

Types and differences of diabetic skin disorders

Several skin disorders are seen exclusively or nearly exclusively in people who have diabetes. These conditions include:

  • Diabetic blisters (also called diabetic bullae or bullosis diabeticorum). Blisters, usually painless, that develop spontaneously on the hands, feet, forearms and lower legs. The lesions contain clear liquid and are not surrounded by redness. These blisters are uncommon, seen most often among men with severe long–standing cases of diabetes. Often diabetic blisters go away on their own within weeks but may reappear. The treatment is controlling glucose (blood sugar) levels.
  • Diabetic dermopathy (also known as shin spots).  Scaly brown patches, usually on the shins, due to changes in the small blood vessels caused by diabetes. These harmless patches do not hurt, itch or erupt and do not require treatment.
  • Diabetic thick skin. Many people with diabetes experience some thickening of the skin. Conditions marked by a pronounced thickening include:
    • Stiff hand syndrome (digital sclerosis). Waxy thickening and tightening of the skin on the back of the hand. The fingers stiffen and lose mobility. Digital sclerosis strikes about one–third of people with type 1 diabetes, according to the American Diabetes Association. In rare cases the elbows, knees or ankles also stiffen. The treatment is controlling glucose levels. Hand stretches and exercises can help.
    • Scleredema diabeticorum  (also called diabetic scleredema). Similar to diabetic sclerosis, except the abnormally thickened skin is on the upper back or back of the neck. Scleroderma diabeticorum is rare. As with diabetic sclerosis, the treatment is controlling glucose levels.
  • Eruptive xanthomatosis. Yellow pea–like bumps, each surrounded by a red halo, that can appear on the skin in cases of uncontrolled diabetes. Eruptive xanthomatosis can itch and usually occurs on the backs of hands, feet, arms, legs and buttocks. It most often strikes young men with type 1 diabetes who have hyperlipidemia (high levels of fat in the blood). However, anyone with diabetes may be affected. Controling diabetes usually resolves eruptive xanthomatosis.
  • Necrobiosis lipoidica diabeticorum (NLD). An irregularly shaped rash similar to diabetic dermopathy but involving spots that are larger and deeper but fewer. Sometimes it begins as a raised reddish area that becomes yellow brown or shiny with a purple outline. The spots can itch, cause pain and break open. NDL is rare, seen more in people with diabetes than nondiabetics, more in women than men, and more in whites than people of other races/ethnicities. It does not need treatment by a physician unless the lesions ulcerate (break open). NLD ulcers have been treated with anti–inflammatory drugs, topical steroids, ultraviolet light and antibiotics.

In addition, many types of skin conditions are more common or more serious with diabetes. These include:

  • Bacterial infections. The many types of infectious bacteria include Staphylococcus (staph), Streptococcus (strep) and Pseudomonas. Such infections at one time were life–threatening for people with diabetes, but improvements in antibiotics and glucose control have changed that. Good skin care reduces the risk. Indicators are inflamed tissues that are painful, swollen, red and warm. Precautions should be taken to avoid spreading these contagious conditions, such as not sharing towels. Bacterial infections include:
    • Boil (also called furuncle). Infection of a hair follicle or a gland. Inflammation clots blood vessels and forms a painful red mass. Common sites include the neck, face, breasts, armpits and buttocks. Treatment can include antibiotics, moist heat and incision.
    • Carbuncle. Deep infection and inflammation of the skin and deeper tissue that ends in an area of dead tissue and pus. A carbuncle features a painful node of reddened skin that erupts pus. Common sites include the back of the neck, back and buttocks. Fever can accompany carbuncles. Treatment can include antibiotics, moist heat and incision.
    • Sty. Infection of the glands of the eyelid. Symptoms include pain, swelling of the eyelid and conjunctivitis (inflammation of the mucous membrane lining the lid). Treatment includes topical antibiotics and application of hot packs to encourage drainage.

Boils, carbuncles and styes are painful but often viewed as minor nuisances. If untreated, however, infections can lead to serious complications such as septicemia (blood poisoning).

  • Impetigo. A highly contagious inflammatory skin disease caused by staph or strep, characterized by crusty red pustules that erupt. Impetigo is most common around the mouth and nostrils. It usually affects children, but diabetes is one of several diseases that increase its risk in adults. Treatment includes antibiotics and keeping the skin clean and dry.
  • Malignant external otitis (MEO, also called necrotizing external otitis). An uncommon but serious and sometimes fatal infection of the external ear canal that can spread to the facial nerves and to the skull (osteomyelitis). Indicators are severe ear pain that worsens at night and discharge of pus and blood from the ear canal.

    MEO is generally caused by Pseudomonas bacteria entering a minor cut in the skin of the ear canal but can be caused by staph infection. It usually affects people with diabetes (especially elders) or other conditions that impair the immune system. Prevention includes avoiding insertion of foreign objects and nonsterile liquids in the ear canal. Treatment may include antibiotics, wound cleaning, surgical debridement and glucose control to help the immune system fight the infection.
  • Fungal infections. A fungus called Candida albicans causes many of the fungal conditions seen in people with diabetes. Hyperglycemia (high glucose) abets the spread of fungi that exist naturally in the human body. Treatment may include antifungal drugs and control of blood glucose. These infections include:
    • Jock itch. Infection of the area around the penis by candida or other fungi. This condition is common among men with diabetes.
    • Nail fungus (onychomycosis). Usually painless infection of the toenails or, less frequently, the fingernails by any of several types of fungi. The nails can turn yellow, brown, black or gray. Antifungal medications sometimes cannot cure nail fungus. Nail fungus is one reason people with diabetes may need to see a specialist such as a podiatrist for toenail care. Prevention includes wearing absorbent socks, shoes made of breathable material and footwear such as shower shoes in locker rooms and public showers.
    • Ringworm. Infection by Microsporum or Trichophyton fungi characterized by red ring–shaped patches that can scale, itch, blister and cause pain. Ringworm can affect the scalp, beard, nails, chest, abdomen and groin.

      Athlete’s foot is a type of ringworm. Athlete’s foot is a contagious, itchy infection that causes cracks in the skin of the feet. It can spread to the toenails and make them thick and difficult to trim. People with diabetes should take athlete’s foot seriously because of the danger of ulcer. Prevention is similar to the measures used to avoid nail fungus.
  • Thrush. Candida infection of the mouth characterized by white curd–like growths and oral pain. Prevention includes good oral hygiene and controlling glucose levels.
  • Yeast infection. Candida infection of the vagina and vulva is common among women with diabetes.
  • Pruritus (itching). People with diabetes often have pruritus because of dry skin, poor circulation, fungal infection or peripheral neuropathy. Scratching an affected area can spread fungal infections. Treatments include limiting baths and showers, using a humidifier and applying a moisturizer.
  • Cellulitis. A broad category of infections, usually bacterial (especially strep or staph) but sometimes fungal, that have spread from the skin to underlying tissues. Symptoms can include fever, headache, chills, low blood pressure and confusion. The skin is warm, red, swollen, tender and prone to blistering.

    Cellulitis usually affects the legs and is a serious condition for people with diabetes. If not controlled early it can spread in the body and damage deep tissues, including bone. Because of cellulitis a nick on the ankle can lead to gangrene and foot or leg amputation.

Cellulitis can be prevented, however, through daily skin and foot care and prompt antiseptic treatment of scrapes and other minor wounds. Treatment of mild cases of cellulitis includes oral antibiotics and pain medications. Treatment of advanced cases may involve intravenous antibiotics and removal of dead tissue.

  • Acanthosis nigricans. A disease marked by brown or tan raised areas on the neck, armpits and groin and sometimes the hands, elbows and knees. It is associated with insulin resistance, obesity and polycystic ovarian syndrome. Losing weight helps resolve the condition.
  • Disseminated granuloma annulare. Ring–shaped or arc–shaped rash, usually red or reddish–brown, that can itch. It can appear anywhere on the body but usually on areas far from the trunk, such as the hands or ears. The cause is unknown.  Medications prescribed for granuloma annulare include corticosteroids. Ultraviolet light has also been used.
  • Vitiligo. Painless patches of white skin due to destruction of pigment–producing cells. The cause is unknown, but vitiligo has been associated with diseases including diabetes and thyroid disorders. A cure has not been found. Sunscreen should be applied to the affected area to prevent sunburn.
  • Yellow skin and nails. These signs are often noted in people with diabetes. The skin discoloring is most evident on the palms and soles. Yellowing is related to changes in how the body uses glucose.
  • Nephrotic systemic fibrosis or nephrogenic fibrosing dermopathy (NSF/NFD). A rare, poorly understood condition that has recently been found in some patients with kidney disease such as diabetic nephropathy or end-stage renal disease. Symptoms may include areas of hardened skin. NSF/NFD has been linked to high doses of a contrast medium called gadolinium used in an imaging test called magnetic resonance angiography (MRA). The U.S. Food and Drug Administration has approved only the lower doses of gadolinium that may be used in magnetic resonance imaging (MRI).

Potential causes of diabetic skin disorders

People with diabetes are more likely to suffer skin conditions for many reasons. Diabetes involves or increases the likelihood of risk factors including:

  • Impaired circulation. Reduced blood flow delays recovery because the infection–fighting white blood cells cannot travel as well. One cause of impaired circulation that is common with diabetes is atherosclerosis (hardening or narrowing of the arteries). Diabetic skin disorders in which impaired circulation can be a factor include bacterial and fungal infections, cellulitis, diabetic dermopathy, diabetic sclerosis, necrobiosis lipoidica diabeticorum (NLD) and pruritus.
  • Suppressed immune system. Impaired ability of white blood cells to fight infections results from the impaired circulation and high glucose (blood sugar) levels common in diabetes. Diabetic skin disorders in which a suppressed immune system can be a factor include bacterial and fungal infections, cellulitis and pruritus.
  • Hyperglycemia. High blood sugar feeds disease–causing microbes and reduces the ability to fight infection. It also causes the body to lose fluid, allowing the skin to dry, crack and let in infectious organisms. Diabetic skin disorders in which poor control of glucose can be a factor include bacterial and fungal infections, acanthosis nigricans, diabetic blisters, diabetic sclerosis, scleroderma diabeticorum, eruptive xanthomatosis, NLD and pruritus.
  • Diabetic neuropathy. Damage to the autonomic nerves (those controlling involuntary functions) makes the body sweat less. Reduced perspiration dries the skin and makes it more likely to crack and allow infections to enter. Damage to the peripheral nerves serving the limbs impairs sensation and increases the risk of foot cuts and other injuries. Diabetic skin disorders in which nerve damage can be a factor include bacterial and fungal infections, cellulitis, diabetic blisters and pruritus.
    Diabetic Neuropathy
  • Hyperlipidemia. Unhealthy amounts of cholesterol and other fats in the blood not only boost the risk of heart attack, stroke and other life–threatening conditions, they can also contribute to skin problems. Eating trans fat and saturated fat contributes to atherosclerosis and can impair circulation. Diabetic skin disorders in which hyperlipidemia can be a factor include acanthosis nigricans, eruptive xanthomatosis and NLD.
  • High blood pressure. Hypertension can worsen the above risk factors. For more information, see Blood Pressure & Diabetes.

Signs and symptoms of diabetic skin disorders

The signs and symptoms of skin disorders caused by diabetes vary according to the particular condition. Localized pain is common. Fever and other symptoms may characterize the serious skin diseases.

The color, shape and size of rashes and lesions can be used to distinguish one condition from another. For more information about the signs and symptoms of the various ailments, refer to Types and differences.

Diagnosis methods for diabetic skin disorders

Visual inspection is usually the first way of noting skin conditions. It is important for people with diabetes to inspect their skin every day, especially the feet. The feet are the part of the body most subject to wear and pressure, and minor wounds in the feet are a common opening for infection and ulcer.

A physician can often differentiate one skin disorder from another through physical examination and noting the patient’s medical history and symptoms. In some cases a sample of skin tissue may be taken for a biopsy. Other diagnostic tools used by the physician depend on the suspected disease (these are noted in Types and differences). The methods include:

  • Blood tests. These include leukocyte (white blood cell) counts to seek indication of infection, erythrocyte sedimentation rate (ESR) to detect inflammation and serum chemistry to determine any change in glucose intolerance. Among the diabetic skin disorders in which blood tests may be used: acanthosis nigricans, bacterial and fungal infections, cellulitis, diabetic blisters, diabetic thick skin, eruptive xanthomatosis and pruritus.
  • CAT scan (computed axial tomography). A rotating x-ray tube generates images from all 360 degrees. A computer compiles the pictures to produce cross–sectional images of the body. The painless test takes up to an hour. The patient may be instructed to fast for several hours beforehand if a dye called a contrast medium is injected. The patient lies down on the x–ray table and is asked to hold still in various positions. Among the diabetic skin disorders in which a CAT scan may be used: malignant external otitis (MEO) and cellulitis.
  • MRI (magnetic resonance imaging). A machine creates a powerful magnetic field to make detailed images of organs and structures. The painless test takes up to an hour and a half. The patient lies still on a table that slides into a narrow passage in the machine. Claustrophobic people may prefer a sedative. Among the diabetic skin disorders in which MRI may be used: MEO and cellulitis.
  • Bone scan. A scanning camera tracks a radioactive tracer compound that is injected into a vein. The tracer accumulates in abnormal areas of bone and often reveals problems months before standard x–rays can. The patient lies down and may be asked to hold still in various positions. This radionuclide imaging test may take about an hour and is painless except for the brief discomfort of injection. A possible side effect is allergic reaction to the tracer. The test emits less radiation than a standard x–ray machine. A bone scan is not used during pregnancy or nursing to avoid exposing the infant to radiation. Among the diabetic skin disorders in which a bone scan may be used: MEO, severe cellulitis and other severe infections.

Prevention and treatment of skin disorders

Lifestyle changes may be one of the first steps in the treatment of skin disorders. Lifestyle changes are particularly important to individuals with diabetes as these individuals are at higher risk for these disorders. Lifestyle changes that can be used to treat and possibly prevent skin problems include:

  • Glucose control. The American Diabetes Association (ADA) notes that intensive control of glucose (blood sugar) can prevent complications of diabetes and yield benefits years after the control is implemented. Good control of glucose should begin as early as possible.
  • Nutritious diet. A healthy diet low in saturated fats and high in fiber can help control weight, blood pressure and cholesterol.
  • Exercise. Regular physical exercise can improve circulation, enhance glycemic control and condition muscles to use oxygen more efficiently. Physical activity can also develop new blood vessels. A fitness plan approved by a physician, such as 30 minutes of exercise each day, can reduce the risk of complications associated with diabetes.
  • Weight control. If an individual is overweight or obese, the chances of developing complications of diabetes increase significantly. Maintaining a healthy weight and body mass index (BMI) is important for control of diabetes and skin disorders.
  • Quitting smoking. Nicotine has been shown to narrow the arteries and restrict the blood vessels. In addition, tobacco use has been linked to high cholesterol and damage to the artery walls. Once of the best ways to reduce complications of diabetes as well as improve glucose control is to quit smoking.

Good hygiene and proper skin care can help prevent many of the skin conditions associated with diabetes. Steps recommended by the National Institutes of Health (NIH) and ADA include:

  • Rinsing and drying well after washing with a mild soap.
  • Avoiding very hot water and excessive bathing, which dry the skin.
  • Using a moisturizer, except between the toes, where dampness can spread fungi.
  • Drinking plenty of water.
  • Wearing cotton underwear to allow air to circulate better around the skin.
  • Inspecting the skin daily, especially the feet, for cuts, sores, redness, swelling, etc.
  • Avoiding harsh antiseptics such as iodine.
  • Controlling glucose to avoid dry skin, which is prone to cracking and infection.
  • Informing a physician of any skin problems.

Treatment of diabetic skin disorders varies widely according to the particular condition. Often antibiotics, antifungals or other medications help. Recent research indicates that, for bacterial diabetic skin infections of the foot, an antibiotic injected once daily may be as effective as an antibiotic that is injected four times a day. Incision or surgical debridement (removal of unhealthy tissue), typically during an outpatient procedure using a local anesthetic, is sometimes needed. Patients may be referred to a dermatologist, a physician who specializes in skin disorders.

A regular program of skin care will prevent many of the dermatological disorders that vex or threaten people with diabetes. A physician can offer more information about these skin conditions and how to diagnose, treat and avoid them.

Questions for your doctor on skin disorders

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about skin disorders and diabetes:

  1. Do I have or am I at risk of any diabetic skin disorders?
  2. What tests might I need to undergo, and what do they involve?
  3. What do my test results show?
  4. What are my treatment options, and which do you recommend?
  5. Could I need surgery if antibiotics or other conservative treatments fail to resolve my skin disorder?
  6. How can I prevent diabetic skin conditions?
  7. When does a skin disorder require medical attention, and when can I treat myself at home?
  8. How often should I check myself for skin disorders?
  9. How often should I be checked by a doctor for skin disorders?
  10. Do I need to see a dermatologist?
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