What are common skin problems in individuals with diabetes?

Common Skin Problems in Individuals with Diabetes

Individuals with diabetes commonly develop several distinct skin problems due to the metabolic, vascular, and neurological changes associated with the disease, including fungal infections, bacterial infections, and diabetes-specific dermatological conditions.

Fungal Infections

• Onychomycosis (fungal nail infection) affects approximately 34% of diabetic patients, nearly three times more frequently than in non-diabetics 1
• Diabetic patients are particularly vulnerable to fungal nail infections due to reduced peripheral circulation, neuropathy, and impaired wound healing 1
• Untreated fungal nail infections can lead to serious complications in diabetics, including:
  • Injury to surrounding tissue from thick, sharp nail edges 1
  • Creation of entry points for bacteria, potentially leading to cellulitis 2
  • Increased risk of limb-threatening complications or amputation 1
• Trichophyton rubrum is the most common causative agent for fungal foot infections in diabetics, followed by T. mentagrophytes 1

Bacterial Infections

• Diabetic foot infections typically begin after a break in the protective skin envelope, often at sites of trauma or ulceration 1
• Acute infections in antibiotic-naïve patients are usually monomicrobial (predominantly aerobic gram-positive cocci) 1
• Chronic wounds develop more complex bacterial flora, including:
  • Staphylococcus aureus (most common pathogen) 3
  • Beta-hemolytic streptococci 1
  • Enterococci and various Enterobacteriaceae 1
  • Obligate anaerobes 1
  • Pseudomonas aeruginosa and other gram-negative rods 1
• Methicillin-resistant S. aureus (MRSA) infections are increasingly common in diabetic patients and are associated with worse outcomes 3

Diabetes-Specific Skin Conditions

• Diabetic dermopathy ("shin spots") - the most common cutaneous manifestation of diabetes 4
• Necrobiosis lipoidica diabeticorum - yellow-brown, atrophic plaques typically on the shins 4
• Granuloma annulare - ring-shaped or arc-shaped grouping of papules 4
• Diabetic bullae (bullosis diabeticorum) - spontaneous, non-inflammatory blisters 4
• Waxy skin syndrome with limited joint mobility 4

Contributing Factors to Skin Problems

• Peripheral neuropathy plays a central role in foot complications:
  • Sensory neuropathy leads to loss of protective sensation 1
  • Motor neuropathy causes foot deformities and abnormal pressure points 3
  • Autonomic neuropathy results in dry, cracking skin due to reduced sweating 3, 4
• Peripheral arterial disease:
  • Increases risk of wound infection 1
  • Adversely affects infection outcomes 1
  • Often involves pedal arteries in diabetics, contributing to poor wound healing 3
• Immunological disturbances:
  • Hyperglycemia impairs overall immunity through various mechanisms 5
  • Polymorphonuclear leukocyte dysfunction increases infection risk and severity 1

Prevention and Management Approaches

• Regular foot examination is essential but may be challenging for diabetics due to obesity, retinopathy, or cataracts 1
• Fungal infections often require combination therapy:
  • Mechanical debridement plus pharmacological treatment for better outcomes 2
  • Topical antifungals for superficial infections 4
  • Systemic antifungals for severe or extensive infections, with careful consideration of potential toxicity 4, 6
• Bacterial infections require:
  • Prompt recognition and treatment 1
  • Appropriate antibiotic selection based on likely pathogens and infection severity 3
  • Surgical debridement for moderate to severe infections 3
• Glycemic control is crucial:
  • Helps prevent skin infections 6
  • Facilitates prompt relief of infection symptoms 7
  • Contributes to bacterial eradication 7

Important Considerations

• Non-painful deep sepsis should be suspected in any diabetic foot with evidence of sensory loss 4
• The combination of infection with peripheral arterial disease significantly increases the risk of poor healing and amputation 1
• Allergic dermatitis is common with topical treatments and may require patch testing for sensitivity 4
• A multidisciplinary approach involving dermatology, infectious disease, and vascular specialists is optimal for managing complex diabetic skin problems 1