Diabetic Skin Diseases: Comprehensive Overview and Management
Diabetic patients are at high risk for developing numerous skin conditions that can significantly impact morbidity, mortality, and quality of life, requiring regular screening, early intervention, and multidisciplinary management.
Common Diabetic Skin Diseases
1. Cutaneous Infections
- Fungal infections (dermatophytoses) - Most prevalent skin manifestation in diabetics (up to 82.6%) 1
- Particularly common in patients with poor glycemic control
- Includes tinea pedis, onychomycosis, and candidiasis
- Management: Topical antifungals for localized infections; oral antifungals for extensive or nail involvement
2. Diabetic Foot Ulcers
- Affects approximately 15-25% of diabetic patients during their lifetime
- Pathophysiology: Combination of peripheral neuropathy, vascular disease, and foot deformities 2
- Risk factors: Loss of protective sensation (LOPS), peripheral arterial disease (PAD), foot deformities, history of previous ulceration 2
- Management:
- Offloading pressure with specialized footwear or devices
- Debridement of nonviable tissue
- Infection control with appropriate antibiotics
- Revascularization when indicated for PAD
- Multidisciplinary approach essential 2
3. Diabetic Dermopathy
- Asymptomatic, light brown, scaly patches typically on shins
- Considered a cutaneous marker of diabetes 3
- Management: No specific treatment required; glycemic control may help prevent new lesions
4. Necrobiosis Lipoidica
- Yellow-brown, atrophic plaques with telangiectasias, typically on shins
- Affects approximately 0.4-1% of diabetic patients 1, 3
- Management: Topical or intralesional corticosteroids; tacrolimus for non-ulcerated lesions
5. Diabetic Bullae (Bullosis Diabeticorum)
- Spontaneous, non-inflammatory blisters on extremities
- Management: Protect intact bullae; treat secondary infections if they occur
6. Acanthosis Nigricans
- Velvety, hyperpigmented plaques in body folds
- Associated with insulin resistance
- Management: Weight loss and improved glycemic control
7. Xerosis (Dry Skin)
- Common in diabetics due to autonomic neuropathy affecting sweat glands 2
- Management: Regular application of emollients and urea-based moisturizers 4
8. Pruritus
- Generalized or localized itching without visible skin changes
- Management: Treat underlying cause; moisturizers; antihistamines if needed
9. Eruptive Xanthomas
- Yellow papules with erythematous halo, associated with hypertriglyceridemia
- Management: Lipid-lowering therapy and glycemic control
10. Scleredema Diabeticorum
- Thickening and hardening of skin on upper back and neck
- Management: Improved glycemic control; physical therapy; phototherapy in severe cases
11. Granuloma Annulare
- Erythematous or flesh-colored papules in ring-like arrangement
- Management: Topical corticosteroids; intralesional steroids for localized lesions
12. Acquired Perforating Dermatosis
- Pruritic papules with central keratotic plug, common in diabetic nephropathy
- Management: Topical retinoids, keratolytics, or UVB phototherapy
13. Charcot Foot
- Progressive, non-infectious destruction of foot joints and bones
- Presents as warm, swollen, red foot without ulceration 2
- Management: Immediate non-weight bearing, urgent referral to foot specialist
14. Peripheral Vascular Disease Manifestations
- Includes hair loss on legs, thin shiny skin, and poor wound healing
- Management: Revascularization when indicated; smoking cessation; lipid management
15. Neuropathic Complications
- Anhidrosis (decreased sweating) or hyperhidrosis (increased sweating) 2
- Management: Emollients for dry skin; antiperspirants for hyperhidrosis
Screening and Prevention
Risk Assessment
- Annual comprehensive foot examination for all diabetic patients 2
- Risk stratification using International Working Group on Diabetic Foot system 2:
- Category 0 (Very low risk): No LOPS, no PAD - Annual screening
- Category 1 (Low risk): LOPS or PAD - Every 6-12 months
- Category 2 (Moderate risk): LOPS + PAD or foot deformity - Every 3-6 months
- Category 3 (High risk): History of ulcer/amputation - Every 1-3 months
Examination Components
- Detailed history of previous ulcers/amputations
- Vascular assessment: Pedal pulses, capillary refill, signs of PAD
- Neurological assessment: 10g monofilament test, vibration perception, pin-prick sensation
- Skin assessment: Calluses, fissures, infections, ulcers
- Foot deformity assessment 2
Management Principles
Glycemic Control
- Well-controlled blood glucose may delay progression of diabetic neuropathy and reduce skin infections 2, 1
- Target HbA1c <6.5% for optimal skin health 2
Skin Care
- Daily skin inspection, especially feet
- Regular moisturizing for dry skin with emollients and urea-based creams 4
- Avoid self-care of ingrown nails and calluses 2
- Proper foot hygiene and appropriate footwear 2
Multidisciplinary Approach
- Diabetic foot ulcers require coordinated care from endocrinologists, dermatologists, vascular surgeons, podiatrists, and wound care specialists 2
- Early referral to specialists for any concerning skin changes
Special Considerations
Diabetic Foot Care
- Well-fitted athletic or walking shoes with pressure-relieving orthoses
- Custom footwear for significant deformities
- Surgical reconstruction for recurrent ulcerations not responsive to conservative measures 2
- Immediate referral for signs of infection or Charcot foot
Infection Management
- Prompt treatment of skin infections is critical
- Empiric antibiotics for suspected infections pending culture results 2
- Consider broader coverage in patients with poor glycemic control
Conclusion
Skin disorders in diabetic patients are common and can lead to significant complications if not addressed promptly. Regular screening, early intervention, and proper skin care are essential components of diabetes management. Maintaining good glycemic control remains the cornerstone of preventing and managing diabetic skin complications.