Diabetic Skin Problems and Diabetes Rash [And how to treat them]

Skin complications in diabetic patients are extremely common. They may even be the primary reason for the diagnosis determination.

About 33% of diabetics will have skin changes caused or complicated by diabetes during their lives. Some of these changes may occur in people who are not affected by diabetes but are much more common in those with diabetes mellitus.

Such conditions provoke itching, fungal and bacterial infections. There are other characteristic conditions of diabetes only.

Typical skin changes for diabetes patients

Diabetic dermatopathy

The condition is also known as “shin spots”. Diabetic dermatopathy is the most common skin pathology in diabetes mellitus and is considered to be a pathologic sign of diabetes. It is presented with small round or oval brown spots on the skin, which are very similar to the age spots.

Multiple well-defined hyperpigmented atrophic macules over bilateral shins (shin spots) – Diabetic dermopathy Source: https://openi.nlm.nih.gov

Usually, they are found on the front surface of the legs, the affected areas are often asymmetrical. These spots do not cause itching or pain. Generally, they do not require therapy. They are due to changes in the small blood vessels of the skin – diabetic microangiopathy.

Diabetic necrobiosis (Necrobiosis lipoidica diabeticorum)

It is a skin disease that is often, but not always, associated with diabetes mellitus. Due to the strong relationship between diabetes and this particular disease, many studies have focused on diabetic microangiopathy as the leading etiological factor.

Necrobiosis Lipoidica Diabeticorum. Erythematous and subcutaneous nodular lesions at the lower limbs Source: https://openi.nlm.nih.gov

Clinically, necrobiosis lipoid is characterized by one or several soft yellowish-brown plaques that slowly develop in the anterior surface of the lower legs for several months. They can continue to exist for years. Some patients also have lesions on the chest, upper limbs and torso.

The lesion begins as brown-red or body-colored papules that slowly develop into a “wax” plaque of varying size.

The slightly raised border retains a brown-red color until the center becomes depressed and gets a yellow-orange shade. On the surface of the glossy and atrophic epidermis, numerous cutaneous telangiectasias of different sizes are observed.

Larger lesions formed by centrifugal enlargement or fusion of smaller lesions acquire a polycyclic configuration. Plaques can ulcerate, as the healed ulcers lead to scarring. The lesions that appear on other parts of the body are raised and plump, with populous, nodular or placental appearance without atrophy and resemble the granuloma annular. The capillary is frequently affected by large atrophic plaques.

Diabetes Bubbles (Bullosis diabeticorum)

They are rarely encountered. Diabetic bubbles are much like blisters caused by skin burns. They can be localized on the palms, feet, forearms, and legs. They often disappear by themselves within a few weeks, but a secondary infection can often occur. Diabetic blisters are rare, but pathognomonic eruption, which mainly affects men.

Bullosis diabeticorum: Presence of tense bubble in the distal phalanx of the second left finger. Absence of cicatricial lesion on the third finger Source: https://openi.nlm.nih.gov

The usual causes of the dermatosis are traumas but can also occur spontaneously without subjective complaints. The size of the individual blister can range from a few millimeters to 5 centimeters.

The pathogenesis of diabetic bubbles is unclear. The most common type is presented with a clear sterile exudate in the veins that heal without leaving scars. Rarely hemorrhage healing process with scarring is present.

The diabetic blisters are associated with poor control of diabetes.

Diabetic rubeosis (Rubeosis diabeticorum)

Rubeosis is permanent or paroxysmal appearing redness of the cheeks, less often the forehead, arms, and legs. The condition is explained with a reduced capillary refill.

Rubeosis diabeticorum
Facial skin redness Source: https://openi.nlm.nih.gov

Pyodermas

Skin infections are more common in people suffering from diabetes due to decreased immunity and disturbed blood supply. Any infection that develops with diabetics tends to be more complicated than usual. People with diabetes have more frequent bacterial infections, including ones affecting the skin – furunculus, carbunculus, furunculosis, folliculitis, impetigo, acne rashes, ulcerations, panartiums, etc.

The patient’s past medical history included diabetes mellitus and hypothyroidism since the age of 23 and 28 years, respectively.
(A) Lichenified verrucous plaques with hemorrhagic ulcers on both ankles and right foot dorsum. (B) Close up view. Source: https://openi.nlm.nih.gov

Typical of diabetes is furunculosis (this condition is a deep infection of the hair follicle leading to abscess formation with an accumulation of pus and necrotic tissue. Furuncles appear as red, swollen, and tender nodules on hair-bearing parts of the body). It may be the first symptom of diabetes.

Mycotic infections

Fungal infections are also extremely common in diabetic patients. Sugar disease creates favorable conditions for the development of candida albicans. These infections often occur in warm, moist places on the skin, most often in the skin folds – interitrigo.

Problem areas are under the chest, around the nail plates, between the fingers (erosion interdigital candidiasis) and the legs, in the corners of the mouth (angulus orris), in the armpits, groins, and genitals (candidal balanitis and vulvovaginitis). Often patients complain about the development of nail fungus. Diabetics also develop multicolored lichen (pitiriazis versicolor).

Stain of Mycosis Fungoid before treatment
cutaneous fungal infection Source: https://commons.wikimedia.org

Granuloma annular

It is a chronic recurrent skin disease, with several forms of clinical presentation – localized, generalized (disseminated), micropapulous, nodular, perforating, subcutaneous. Annular granuloma may be associated with diabetes, predominantly the disseminated, less localized form of the granuloma annular.

Granuloma annular
Granuloma annular Source: https://commons.wikimedia.org

It is clinically presented with thick lenticular papules and nodules, with the color of the skin or pink-violet, merging in the form of variously abundant annular plaques. These plaques usually have a smooth surface.

Pre-emergence sites are the proximal parts of the upper limbs, the upper body, the back of the palms and soles, the occipital zone, the face. Their number ranges from a single plaque to several hundred, up to 5 cm in diameter. Subjective complaints are usually absent, but sometimes there may be moderate non-permanent itching.

Diabetic skin sclerosis

Skin hardening is not a rare phenomenon for people suffering from diabetes. In the course of diabetes, fibrosis is manifested in two ways – Scleroderma-like syndrome and Scleredema diabeticorum.

The pathogenesis of dermatosclerosis has not been clarified yet. Histological changes in connective tissue are related to those in scleroderma – edema in the upper derma, collagen structure deterioration, collagen type 3 accumulation and acid mucopolysaccharides.

Scleroderma-like syndrome is part of the “Diabetic Hand Syndrome”, affects about 1/3 of patients with insulin-dependent diabetes and clinically resembles acrosclerosis in systemic progressive scleroderma. It is expressed by wax density and skin induction on the dorsal surface of the palms and fingers (sclerodactilia). The condition provokes a localized thickening and tightness of the skin of the fingers or toes.

The process can extend to the forearms and even torso, simulating a proximal form of cutaneous sclerosis in progressive scleroderma. The skin in the areas of the interphalangeal joints becomes uneven, rough.

Active and passive movements of the joints are limited and the fingers are in moderate flexion. The progression of age and the duration of diabetes are both risk factors for Scleroderma-like skin changes. The condition is not affected by blood sugar levels.

Diabetic Sclerosis Source: https://openi.nlm.nih.gov

Scleredema diabeticorum is erythema and skin induction on the upper torso and occurs in up to 15% of people with diabetes. The affected areas are sharply bounded by the adjacent healthy skin. Unlike the classic Scleredema adultorum Buschke, which is most common after viral or streptococcal infections, diabetic patients can develop dermosclerosis, which can spread to the proximal parts of the upper limbs.

Men are 10 times more prone to developing this condition, comparing to women. It starts gradually, it is difficult to diagnose it in the beginning, but all diabetes patients should have in mind that the risk factors for dermatosis are obesity and insulin-dependent diabetes. The course of the disease is influenced by glycemic control

Xanthomas

The poor control of diabetes can lead to the development of xanthomas – yellow papules, most often on the back of the hands and feet. Xanthomas are associated with elevated levels of lipids in the blood. Xanthomas are cutaneous manifestations of lipidosis in which lipids accumulate in large foam cells within the skin.

Eruptive xanthomas. Scattered yellow and white papule bursts on the front of the thigh. Source: https://openi.nlm.nih.gov

Diabetic gangrene

Gangraena diabeticorum is an untreated foot infection or a severely poor blood circulation that causes lack of oxygen to the feet. It is located on the toes and heel. It is represented by black necrotic areas demarcated by healthy tissues with an erythematous inflammatory zone. Unless rapid measures are taken, amputation may be needed.

Gangrene of the 1st to 4th toes of the right foot in person with diabetes.
Source: https://commons.wikimedia.org

Diabetes ulcer – Malum perforans

The diabetic ulcer is round, deep, difficult to heal, most often occurs on the feet and at the base of the thumb. It is similar to the trophic ulcers of tarsus dorsalis and endartritis oblitrans.

Such ulcer can occur as a result of various factors, such as mechanical changes in conformation of the bony architecture of the foot, peripheral neuropathy, and atherosclerotic peripheral arterial disease, all of which occur with higher frequency and intensity in the diabetic population.

A 63-year-old female with diabetes and rheumatoid arthritis presented with a chronic venous ulceration (2 cm X 2.6 cm) to the dorsal aspect of the right leg. Source: https://commons.wikimedia.org

Acanthosis Nigricans

Acantosis nigricans is a skin disease manifested by symmetrical, hyperpigmented, hypertrophic and papillomatous changes, affecting the flexor body parts and areas subjected to intense friction. It is most commonly associated with insulin resistance and overweight, less often with neoplasm of internal organs.

The risk factors for the development of acanthosy nigricans are a family history of available acanthosis nigricans or diabetes mellitus.

Acanthosis nigricans
Source: https://commons.wikimedia.org

The exact mechanism for the appearance of dermatosis remains unknown. Cell insulin receptors can not bind insulin for several reasons – genetic and functional defects in the receptors themselves, the presence of anti-insulin receptor autoantibodies, gene and functional enzyme abnormalities leading to inability to activate tyrosine kinase. At the same time, the high concentration of circulating unbound insulin stimulates expression of the insulin-like growth factor receptor of keratinocytes, resulting in epidermal and fibroblast proliferation.

Diabetic patients should also have in mind that the disease can be associated with a family history or a high number of endocrinopathies, such as Cushing’s syndrome, acromegaly, Addison’s disease, ovarian polycystic syndrome, hypothyroidism, hyperandrogenemia.

It is presented with symmetrical hyperkeratotic pigment plaques (varying from light brown to black), located in the body folds, most often in the axillae, in the neck zone, on the palms. Histologically, hyperkeratosis, hypergeneous and melanocytic pigmented epidermis pigmentation, moderate acanthosis, increased melanocytes, papillomatosis and fibroblast proliferation in the dermis are observed.

Skin Care for Diabetics

  • Skin care for diabetics does not really differ from skin care in people who do not suffer from diabetes. There are some tips on how to keep it healthy.
    Use a soft, neutral soap, rinse well and dry. This includes dryness between toes and hands where water can be retained.
  •  Use a moisturizing body lotion to keep your skin soft and hydrated. This type of cosmetics is widely available and can make a huge difference.
  • Keep well hydrated, this will keep your skin hydrated and healthy as well.
  • Wear loose cotton linen. It allows the skin to breathe.
  • Consider wearing special socks and shoes if you have a neuropathy and worry about the condition of your feet.
  • Be careful with any dry and red spots on your skin and be prepared to consult a doctor if you have any doubt that something is wrong.
  • Monitor carefully all areas affected by neuropathy and look for a professional approach as early as possible in case you notice any changes.
  • Consult a doctor if you have persistent dry skin, as this can lead to infections that can quickly turn into severe complications.

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