Diabetes: Dr. Martin Gozar - Complete Review Including Diabetes & Skincare

Skincare complications in diabetes

Diabetes, a chronic metabolic disorder, affects approximately 463 million adults globally, with a significant impact on morbidity and mortality rates. Skin complications are prevalent in diabetes, affecting up to 80% of patients and leading to complications such as diabetic dermopathy, skin infections, and xerosis

Microvascular and macrovascular complications are common, impacting small and large blood vessels. Microvascular complications involve diabetic retinopathy, nephropathy, and neuropathy. Macrovascular complications include coronary artery disease, stroke, and peripheral vascular disease. Risk factors for complications include poor blood glucose control, high blood pressure, high cholesterol, smoking, and obesity. 

Additionally, many skin complications arise in those with diabetes. Diabetic dermopathy is characterized by light brown or red scaly patches on the skin. It is associated with microvascular complications due to prolonged high blood sugar levels. Prevention involves maintaining good blood sugar control and protecting the skin from injury.

Diabetic blisters (bullosis diabeticorum) are uncommon blisters on various body parts. They result from long-standing uncontrolled blood sugar levels and neuropathy. They are typically painless and resolve on their own; indicative of underlying complications.

Digital sclerosis affects skin and joints, causing thickening and tightening in fingers, toes, and hands. It’s associated with long-term exposure to high blood sugar levels and poor circulation. It impacts mobility and daily activities, emphasizing the need for early intervention.

Diabetic foot ulcers arise from a combination of high blood sugar, neuropathy, and poor circulation. Nerve damage leads to unnoticed injuries, poor blood flow hinders healing, and ulcers may result. It carries a high risk of infection and amputation, stressing the importance of proactive foot care.

Individuals with diabetes are prone to styes, boils, carbuncles, folliculitis, and urinary tract infections. Weakened immune systems and reduced sensation contribute to increased susceptibility.

Acanthosis nigricans are dark, thickened patches of skin linked to insulin resistance and obesity. They’re not harmful but serve as a visible indicator of underlying health issues. Management involves lifestyle modifications, addressing insulin sensitivity, and treating underlying conditions.

Organizations like the American Diabetes Association emphasize regular skin assessments, patient education, and prompt intervention. Education includes proper cleansing, moisturizing, and skin inspection, with recommendations for suitable emollients and moisturizers. Healthcare professionals are advised to prescribe antimicrobial therapies, dressings, or topical treatments as needed.

Emollients play a crucial role in hydrating the skin, preventing dryness, and relieving symptoms like itching. Topical treatments, including antibiotics, antifungals, and steroids, are valuable in managing bacterial and fungal infections, as well as inflammation. Selection should be based on the specific skin complication, with close monitoring to ensure safe and effective use.Proper skin pH maintenance is highlighted, as high pH products may exacerbate conditions like candidal intertrigo. Regular cleansing and moisturizing, particularly with ceramides-containing products, can sustain physiological skin pH, enhance barrier function, and potentially reduce complications. Recognizing and managing diabetes-related skin conditions is vital for improving patients' quality of life and preventing serious adverse effects. Consistent skin care, including moisturizer application, emerges as a valuable measure to address skin barrier dysfunction in diabetes.

References:

David P, Singh S, Ankar R. A Comprehensive Overview of Skin Complications in Diabetes and Their Prevention. Cureus. 2023 May 13;15(5)

Epidemiology of diabetes and diabetes-related complications. Deshpande AD, Harris-Hayes M, Schootman M. Phys Ther. 2008;88:1254–1264

Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International Diabetes Federation Diabetes Atlas, 9(th) edition. Saeedi P, Petersohn I, Salpea P, et al. Diabetes Res Clin Pract. 2019;

Kirsner RS, Yosipovitch G, Hu S, Andriessen A, Hanft JR, Kim PJ, Lavery L, Meneghini L, Ruotsi LC. Diabetic Skin Changes Can Benefit from Moisturizer and Cleanser Use: A Review. J Drugs Dermatol. 2019 Dec

Diabetes is a disease the is caused due to the sugar levels not being processed correctly in the body. Diabetes affects 34.2 million adults in the US. It is a very common disease and although there is no cure for diabetes, it can be managed with medications. Diabetes is a prevalent disease and it is important to ensure that the healthcare providers ensure that patients are adhering to their medications. If diabetes is not managed properly then it can lead to many comorbidities which means that a person with diabetes has a higher risk to develop another disease. These diseases can include high blood pressure, heart disease, obesity, high cholesterol, and more.

For a very common disease, diabetes can have many serious complications as well if not managed properly. Having too much glucose in the body can affect other organs and parts of the body; these that can be affected include the kidneys, heart, nerves, eyes, feet, skin conditions as well as the mouth and other areas as well. These complications can be very detrimental to one’s health.

Diabetes can have an effect on the blood. It reduces the blood flow to certain areas in the body which can cause these areas to not get the correct nutrients they need and leads to them losing their function as well as harming the surrounding areas.

The skin is the biggest organ in the body which can be affected by diabetes as well. Diabetes may cause reduction in the circulation of blood flow which can lead to certain skin conditions as well as infections on the skin. There are signs that can appear on the skin that show that your diabetes needs to be treated. These signs include the following: yellow patches on the skin which can be swollen and become hard on the skin, darker areas of skin that feels like velvet which if noticed then must get tested for diabetes, there can also be skin infections which appear as hot, swollen skin which can be painful and there are sometimes tiny blisters, open sores and wounds called diabetic ulcers which can occur due to poor circulation and nerve damage, as well as additional skin conditions.

How can you take care of your skin if you have diabetes? It is important to take care of the skin and moisturize it daily in order to prevent cracks which may lead to infection. Creams and ointments are a great way to moisturize your skin more than lotions. If you have dry, cracked heels then apply cream that includes 10 % to 25% urea daily until the skin heels. When bathing, use gentle cleansers that are suited for sensitive skin so that it would not irritate the skin. If any infections develop then get medical help immediately and do not wait out on the infection to go away on its own. Signs of an infection can be swollen or discolored skin, pain or tenderness, wound that has pus or fluid, as well as build-up beneath fingernail or skin. Make sure to treat all cuts, scratches, and wounds immediately by washing them with soap and water as well as applying antibiotic ointment if recommended by MD. Always check your feet and skin for any wounds in order to treat them immediately and avoid skin infections.

“Dermatologist-Recommended Skin Care for People with Diabetes.” American Academy of Dermatology, www.aad.org/public/diseases/a-z/diabetes-skin-care.

“Diabetes Complications.” MedlinePlus, U.S. National Library of Medicine, 24 June 2021, medlineplus.gov/diabetescomplications.html.

“Diabetes: 12 Warning Signs That Appear on Your Skin.” American Academy of Dermatology, www.aad.org/public/diseases/a-z/diabetes-warning-signs.

“What Is Diabetes?” National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Department of Health and Human Services, www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes.

Diabetes affects nearly 10% of the U.S. population. Out of these roughly 23 million people with diabetes, nearly 7 million people remain undiagnosed. It is not only crucial to regularly check a patient’s A1C (glycated hemoglobin) and blood glucose levels to see if he or she has diabetes but also crucial to make the distinction between Type 1 (T1DM) and Type 2 Diabetes (T2DM). Type 1 (accounts for 5% of cases) is when a person cannot produce insulin and Type 2 (accounts for 95% of cases) is when a person can produce insulin but his or her body doesn’t know how to use the insulin. Certain key risk factors for T2DM include obesity, a history of CVD, and smoking.

There are 3 classic symptoms of hyperglycemia are- 1. Polyuria, 2. Polyphagia, and 3. Polydipsia. Common warning signs on the skin include digital sclerosis (skin hardening), blisters (diabetic bullae), and open sores and wounds (diabetic ulcers). One of the most common microvascular complications is diabetic retinopathy (DR) which is also the leading cause of blindness in adults.

There are 3 key features of diabetic retinopathy- hyperglycemia and retinal microvasculopathy, inflammation, and retinal neurodegeneration. The earliest signs/symptoms include change in blood flow and dilation of blood vessels. Vascular endothelial growth factor (VEGF) upregulates as a result of retinal hypoxia and ischemia. Inflammation in DR was demonstrated in diabetic animal models and patients. In diabetic rats, retinal neurodegeneration was demonstrated as early as one month in diabetic rats post-induction of diabetics. This not only demonstrates how unfortunately easy it is to get diagnosed with DR in a diabetics patient but also leads as a segway to potential treatments of DR.

Current and up-and-coming treatments of diabetic retinopathy include anti-angiogenic therapy, anti-inflammatory therapy, laser therapy, and other therapeutic agents including cardiolipin-targeting peptide, alpha-lipoic acid, and darapladib. Angiogenesis is when a person’s new blood vessels are formed from pre-existing vessels. Anti-VEGF drugs are included under anti-angiogenic therapy and FDA-approved drugs included in this treatment are Ranibizumab (Lucentis), Aflibercept (EYLEA), and Pegaptanib (Macugen). All three of these therapeutic agents have effectively demonstrated to improve a patient’s best-corrected visual acuity (BCVA). However, a major downside of these 3 agents are that they all cause an elevation in a patient’s intraocular pressure (IOP).

The only two anti-inflammatory FDA-approved drugs for DR are the DEX implant (Ozurdex) and the FA insert (Iluvien, 0.2 ring). Both of these steroids are administered through the eye and result in greater BCVA improvement. Adverse effects of both of these treatments include cataract surgery and elevation in a patient’s IOP. Triamcinolone has an off-label as an anti-inflammatory drug used to treat DR as well. Traditional laser treatments such as laser photocoagulation have been the gold standard for the treatment of diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). As essential as these novel treatments for DR are, it is even more important to recognize the underlying causes of DR and how to preclude them from occurring in the first place.

References-

Cohen Sabban, Duff M, et al. Diabetes: 12 warning signs that appear on your skin. American Academy of Dermatology Association. https://www.aad.org/public/diseases/a-z/diabetes-warning-signs

Wei Wang, Amy C. Y. Lo. Diabetic Retinopathy: Pathophysiology and Treatments. International Journal of Molecular Sciences. 2018, June.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6032159/

RxPrep NAPLEX Review 2021. Chapter 44: Diabetes. Page 640.

Diabetes is a difficult disease to manage and comes with a plethora of possible complications. Uncontrolled sugar levels in diabetic patients is known to cause many effects including effects on the skin. These effects can involve the microvasculature, extravascular dermal matrix, dermo-epidermal junction, epidermis, hair follicles, sweat glands and hypodermis. Most commonly, uncontrolled diabetes can cause poor perfusion and blood supply to the extremities, and can compromise the skin barrier. Pharmacists are responsible in educating their patients living with diabetes to be proactive about their skin care and to properly manage any skin conditions they develop. The management of diabetes complications is just as important as the management of diabetes itself.

Diabetic ulcers and diabetic foot syndrome is a complication seen often in this patient population, especially in institutions like hospitals. This can result from things like neuropathy, trauma to the feet/extremities, infection, peripheral vascular disease or impairment of wound healing. Diabetic ulcers usually evolve from a site of trauma/wound or callus. Due to underlying diabetic immunosuppression, simple foot issues like calluses or cuts are very difficult to heal. They are also more prone to infection. Because of neuropathies, a patient might not even notice they have an injury or issue on their feet, and might not be able to see that there’s anything going on. Overall there are many ways to prevent diabetic foot syndrome.

The best way to prevent complications like diabetic foot syndrome is to control glucose levels, blood pressure and cholesterol. Keeping the skin hydrated is also key as dry skin can compromise the body’s ability to fight infection. A pharmacist can counsel their diabetic patient how to moisturize to prevent chapping, to not over bathe or use very hot water while bathing, and to not use moisturizer between the toes. Loose fitting clothing is necessary to maintain good blood flow to the extremities. If the skin does get injured, it’s important to keep the area clean, treat any cuts (even minor) right away, wash with soap and water and cover with protective gauze.

When patients do experience something like an open ulcer on their foot, the treatments include wound care and wound debridement, getting wound cultures for antibiotic treatment, and better diabetes management. If an ulcer becomes infected, it can be a skin and soft tissue infection that can spread deeper into the skin and worsen to osteomyelitis. An infection would present as erythema, warmth, tenderness, swelling, induration, or purulent secretions coming out of the wound. More serious infections would have systemic complications like changes in vital signs.

Overall, pharmacists should tell their patient the importance of checking their feet every day and wearing proper footwear. They should also follow up with their doctor often and get podiatry check-ups. Keeping their diabetes in check is the best way to prevent any skin complications.

Amy C Weintrob, MD Daniel J Sexton, MD. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. Uptodate. Jan 2021.