5/20- Diabetes & Skin Care (250 words)

Diabetes Treatment – Non-Insulin Part 2

SGLT2 inhibitors work by inhibiting SGLT2 which is a transporter. “These transporters are an ideal target for the treatment of diabetes because they are responsible for roughly 90% of filtered glucose reabsorption. The normal renal threshold for reabsorption of glucose corresponds to a serum glucose concentration of 180 mg/dL. In patients with type 2 diabetes, this threshold can increase and the expression of the SGLT2 can be up-regulated causing a maladaptive response that worsens hyperglycemia” (NIH). The mechanism of SGLT2 inhibitors promotes glucose excretion through urine and decreases blood glucose concentrations leading to improved glycemic control and cardiovascular and renal protection.

Examples of SGLT 2 inhibiters are canagliflozin, dapagliflozin, empagliflozin, bexagliflozin, and ertugliflozin. These drugs all end with the suffix -gliflozin. They have showed benefits in patients with heart failure, CKD, and ASCVD. SGLT2 inhibitors are recommended for patients who have theses comorbidities. Some warnings associated with SGLT2 inhibitors is that they can cause ketoacidosis, genital mycotic infections, UTIs, and hypotension. The reason for increased risk of UTI and genital infections is the increased glucose excretion, which can lead to these side effects. With canagliflozin and bexagliflozin specifically, there is an increased risk of foot and leg amputations. Some side effects of SGLT2 inhibitors is that they cause increased urination and thirst. There is also a hyperkalemia risk with canagliflozin.

Sulfonylureas are insulin secretagogues which means they work by stimulating insulin secretion from the pancreatic beta cells to decrease postprandial blood glucose. Older first-generation sulfonylureas include drugs like chlorpropamide, tolazamide, and tolbutamide. These drugs have prolonged duration of action and have a higher risk of hypoglycemia, therefore they are not to be used. The sulfonylureas that can be used today are glipizide, glimepiride, and glyburide. These drugs all start with a G and end with and -ide. A contraindication to sulfonylureas is a sulfa allergy. Some warnings and sides effects of sulfonylureas are hypoglycemia, weight fain, and nausea. IT can be expected that sulfonylureas decreased A1C by 1-2%. Glipizide IR is to be taken 30 minutes before a meal and doses may need to be help if the patient is NPO. Glimepiride and glyburide are not recommended in elderly patients according to the Beer’s criteria.

Meglitinides are another class of drugs that also act as insulin secretagogues. They differ from sulfonylureas in that that have a faster onset (15-60 minutes) and a shorter duration of action. Examples of metglinides are repaglinide and nateglinide. Warmings and side effects of metglinides are hypoglycemia and weight gain. It is also advised that if a meal is skipped the dose should also be skipped.  Repaglinide interacted with clopidogrel and is contraindicated with gemfibrozil.

DPP-4 inhibitors “prevent the enzyme DPP 4 from breaking down incretin hormones, glucagon-like peptide 1 and glucose insulinotropic polypeptide (GIP) which enhances the effects of these incretins” (UWorld RxPrep). This helps with glucose regulation because they increase glucose dependent insulin secretion and decrease glucagon secretion. Examples of DPP 4 inhibitors are sitagliptin, linagliptin, saxagliptin, and alogliptin. These drugs in the suffix -gliptan. DPP 4 inhibitors have a a warning of pancreatitis, severe arthralgia, acute renal failure, and risk of heart failure is seen in saxagliptin and alogliptin. DPP 4 inhibitors are not to be used with GLP 1 agonists because they have overlapping mechanisms.  

UWorld RxPrep NAPLEX Review 2025 Chapter 44 Diabetes Page 584

Diabetes Treatment – Non-Insulin Part 1

Non-insulin treatments for diabetes play a critical role in managing type 2 diabetes mellitus, where insulin resistance and impaired beta-cell function are predominant. These therapies aim to control blood glucose, improve insulin sensitivity, and reduce the risk of complications. The treatment regimen is tailored to individual patient needs, considering factors like age, comorbidities, and glycemic goals.

Biguanides, primarily metformin, are the first-line therapy for T2DM and can be used in prediabetes as well. Metformin decreases hepatic glucose production and improves insulin sensitivity in peripheral tissues. Metformin also decreases intestinal absorption of glucose. Metformin decreases A1C by 1-2%, is weight neutral, and doesn’t cause hypoglycemia. Metformin comes as “a tablet, an extended-release (long-acting) tablet, and a solution (liquid) to take by mouth. The solution is usually taken with meals one or two times a day. The regular tablet is usually taken with meals two or three times a day” (Medline). Extended release tablets are to be swallowed who and it can be expected that a ghost tablet (empty shell) can be in the stool. A common side effects is gastrointestinal issues, but the dose can be titrated wo help manage this. Metformin’s use is contraindicated in severe renal impairment due to the risk of lactic acidosis. Metformin is also contraindicated in a patient with an eGFR < 30 or has acute or chronic metabolic acidosis. Another warning associated with metformin is a vitamin B12 deficiency that can cause symptoms like peripheral neuropathy and cognitive impairment. Because of this, it is advised that B12 levels are monitored periodically (about every 1-2 years).

GLP-1 receptor agonists mimic and are analogs of the incretin hormone GLP 1. GLP 1 enhances insulin secretion, reduces glucagon secretion, slows gastric emptying, reduces appetite, and promotes weight loss. These drugs end with the suffix -tide. Examples of GLP-1 agonists include liraglutide, semaglutide, dulaglutide, exenatide, and tirzepatide. “Liraglutide, dulaglutide, and SC semaglutide are recommended in patients with ASCVD (or high risk) and as an alternative in CKD because of their demonstrated cardiovascular benefits” (UWorld RxPrep). All GLP 1 agonists are subcutaneous injections, except semaglutide which comes as an oral tablet as well. These agents are injectable but have shown significant efficacy in glucose and weight management. Some side effects and warnings to be mindful of regarding GLP 1 agonists is that all GLP 1 agonists, except Byetta, come with a risk of thyroid c-cell carcinomas. There are also warnings of pancreatitis, acute kidney injury and kidney disease associated with GLP 1 agonists. GLP 1 agonists are to not be using with DPP 4 inhibitors as they have overlapping mechanisms. Some counseling points associated with GLP 1 agonists are that the injections are to be administered in the abdomen , a new pen needle is to be used for every injection, insert the pen needle at 90 degrees into the abdomen, press the injection button for 5-10 seconds before removing the needle, and rotate injection sites with each injection. Once the injection is completed the pen needles is to be disposed of appropriately in a sharp’s disposal container. Pens should not be stored with a needle attached.

UWorld RxPrep NAPLEX Review 2025 Chapter 44 Diabetes Page 582

https://medlineplus.gov/druginfo/meds/a696005.html#:~:text=Metformin%20helps%20to%20control%20the,of%20glucose%20in%20the%20blood

Diabetes mellitus presents a significant challenge to public health in the United States, contributing to mortality rates with its disruptive effects on metabolism. The condition manifests primarily in two forms: Type 1, characterized by the immune system's destruction of insulin-producing pancreatic cells, and Type 2, where the pancreas fails to produce adequate insulin or the body develops resistance to its effects. Uncontrolled diabetes not only leads to severe symptoms but also escalates mortality rates, underscoring the urgent need for effective management strategies to mitigate its consequences.

Among the chronic complications associated with poorly managed diabetes, diabetic foot ulcers emerge as a major concern, followed by retinopathy and nephropathy. About one-quarter of individuals diagnosed with diabetes may eventually develop foot ulcers, highlighting the critical role of diabetic care. These ulcers appear as open wounds or sores on the foot and result from a complex interplay of factors. Initial symptoms, such as tingling sensations and numbness, often go unnoticed by patients. Reduced blood circulation, compounded by prolonged diabetes, worsens the condition, while external factors like trauma and foot deformities further predispose individuals to infections, emphasizing the importance of proactive podiatric intervention to prevent severe outcomes like amputation.

Preventive care forms the foundation of managing diabetic foot ulcers, focusing on maintaining optimal blood glucose levels and meticulous wound hygiene to prevent infections. Measures to alleviate pressure on vulnerable areas, especially the soles of the feet where ulcers commonly occur, play a crucial role in reducing risks. Customized footwear designed to meet the specific needs of diabetic patients provides a practical solution, offering options ranging from wider shoes to orthotic designs that enhance comfort and support during the healing process. Simultaneously, careful wound care, including regular dressing changes and the application of topical medications, remains essential in promoting optimal healing outcomes. Given the extended healing period characteristic of diabetic wounds, ongoing collaboration with healthcare providers, such as endocrinologists and primary care physicians, ensures comprehensive oversight and timely interventions to address emerging concerns.

Addressing the underlying triggers of foot ulcers, such as dryness and cracking, requires proactive measures to preserve skin integrity and moisture balance. While over-the-counter remedies like Vaseline and emollient creams provide temporary relief, prescription-grade formulations like ammonium lactate, available in generic form and under brand names such as AmLactin, offer more sustained benefits in maintaining skin hydration. Similarly, alternatives like Santyl, a prescription option replacing petrolatum jelly, offer viable options for managing wound healing dynamics, highlighting the diverse range of therapeutic modalities available to diabetic individuals.

In conclusion, diabetes mellitus poses a multifaceted challenge to public health, characterized by metabolic dysregulation and increased mortality risks. Effective management of associated complications, particularly diabetic foot ulcers, hinges on a proactive approach encompassing preventive measures, specialized care interventions, and diligent wound management practices. By embracing a comprehensive care paradigm that addresses both systemic and localized aspects of diabetes, healthcare providers can empower individuals to navigate the complexities of this chronic condition while minimizing its detrimental impact on overall health and well-being.

Lauri, C., Leone, A., Cavallini, M., Signore, A., Giurato, L., & Uccioli, L. (2020). Diabetic Foot Infections: The Diagnostic Challenges. Journal of clinical medicine, 9(6), 1779. https://doi.org/10.3390/jcm9061779

Murphy-Lavoie HM, Ramsey A, Nguyen M, et al. Diabetic Foot Infections. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441914/

Diabetes mellitus is one of the leading causes of death in the United States and is a contributing comorbidity to increasing mortality. Diabetes is a metabolic disease where the pancreas does not produce enough insulin or can not use insulin appropriately. Type 1 diabetes is an autoimmune disease where the body destroys insulin-producing pancreatic beta cells. In type 2 diabetes, the pancreas cannot produce enough insulin to take in sugar and patients become resistant to insulin. Uncontrolled diabetes produces life-threatening symptoms and increases mortality.

One of the leading chronic complications of uncontrolled diabetes is diabetic foot ulcers, followed by retinopathy, then nephropathy. Nearly a quarter of diabetes patients may develop a foot ulcer at some stage of their diagnosis. A diabetic foot ulcer is an open sore or wound occurring on the foot. The formation of diabetic foot ulcers is complex. Initial stages include tingling sensations and numbness which many patients overlook. Reduced blood flow and duration and diabetes play the biggest roles in the deteriorating condition. Other external factors such as trauma, dryness of the skin, cracks, and any foot deformities such as hammer toes and bunions further trigger the potential of an infection on the foot. It is essential to seek care from a podiatrist to address such concerns and reduce the risk of amputation. 

Preventative care is the first-line treatment for diabetic foot ulcers. Managing blood glucose levels and frequently cleaning any wounds on the foot are vital in infection prevention. It is ideal to not apply pressure to the bottom of the foot, the most common area of ulcers. During the healing period, patients may walk with special footgear or simply reduce walking until the ulcer has healed. Appropriate footwear should be researched as wider shoes are now being sold and tight shoes can further aggravate any injuries. Orthotic shoes are also available on the market and have shown promising benefits. Wound management includes frequently applying dressings and topical medications. As a diabetic, wound healing takes longer than a nondiabetic, which is why it is important to continue following up with your endocrinologist or primary care physician.

With dryness and cracking being a triggering factor in foot ulcers, patients can use over-the-counter and non-medicated products to alleviate the dryness. Products such as Vaseline and heavy creams can provide minimal benefits. Ammonium lactate is commonly prescribed to keep the foot moisturized and is available as a low-cost generic. It is also available over-the-counter as the brand AmLactin. A prescription alternative to petrolatum jelly is Santyl, a collagenase ointment used in healing damaged tissue from chronic skin ulcers and burns. In cases of severe diabetic foot ulcers that require hospital intervention, oral or intravenous antibiotics are used depending on the involvement of the joint or bone and the size of the wound. Patients should be educated on preventative measures such as wound care and glycemic control to prevent extensive complications such as amputation and numbness in the feet. 

References

1. https://www.who.int/news-room/fact-sheets/detail/diabetes

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664939/

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9791567/

Diabetes is a chronic disease characterized by high blood glucose or hyperglycemia from one of two reasons: when the pancreas is unable to produce enough insulin, aka Diabetes Mellitus Type 1, or when the body is unable to effectively use the insulin being produced, which is Diabetes Mellitus Type 2. Insulin is an important hormone with the key function to regulate blood glucose. From 2001 to 2021, diabetes prevalence significantly increased among US adults 18 years or older. According to the CDC, about 38 million Americans have diabetes (mostly type 2) and 1 in 5 people are not even aware they have it. In 2021, diabetes was the 8th leading cause of death in the United States.

In diabetes type 1, the genetically susceptible individual is exposed to a trigger which can be either viruses, early exposure to cow’s milk prior to age 1, dietary or other environmental exposures. This trigger may lead to beta cell destruction. Beta cells in the pancreas are responsible for producing insulin and as a result, the body is unable to produce insulin. In diabetes type 2, increased glucose reabsorption, decreased glucose uptake, neurotransmitter dysfunction, increased hepatic glucose production, increased glucagon secretion, decreased insulin secretion, and decreased incretin effect all play a role in the pathogenesis of the disease. Diabetes type 2 is more common in adults, however it is now being seen more often in children as well due to sedentary lifestyles, obesity, and the normalizing of unhealthy diets.

Asymptomatic overweight or obese adults should be screened for T2D or prediabetes if they have risk factors such as a first-degree relative with diabetes, if they are a high-risk race/ethnicity (black, Latino, Native American, Asian American, Pacific Islander), a history of cardiovascular disease, hypertension, HDL <35 mg/dL and/or TG >250 mg/dL, PCOS, and physical inactivity. Diabetes leads to many complications, which are characterized into macrovascular and microvascular complications. The macrovascular complications include diseases primarily of the coronary and peripheral arteries, such as atherosclerosis leading to increased risk of stroke and cerebrovascular disease, hypertension, etc. The microvascular complications include nephropathy, neuropathy, and retinopathy. Diabetic retinopathy is the leading cause of blindness in working-age adults, while diabetic nephropathy can lead to end-stage renal disease. Diabetic neuropathy, on the other hand, can result in severe pain, numbness, and tingling sensations in the extremities.

The skin complications resulting from diabetes includes diabetic dermopathy, diabetic blisters, digital sclerosis, diabetic foot ulcers, unnoticed injuries or sores, infections, and more. Diabetic dermopathy is also known as shin spots as it frequently appears on the lower legs, or specifically the shins. It is characterized by light brown or red scaly patches on the skin, and they may be slightly raised or depressed. The patches may fade but can persist for some individuals and is not a serious conditions. Diabetic blisters are characterized by fluid-filled sacs that develop on various body parts, including the legs, feet, hands, and arms. They are larger than typical blisters and may suddenly emerge on seemingly unaffected skin. Digitial sclerosis is characterized by the thickening and tightening of the skin in the joints of the fingers, toes, and hands, leading to a waxy appearance and texture. Diabetic foot ulcers are a serious complication that can arise due to the combination of high blood sugar levels, nerve damage (neuropathy), and poor blood circulation (peripheral arterial disease) commonly seen in diabetes. Unnoticed injuries or sores comes from a reduced sensation in the feet and these injuries can lead to infection.

It is essential for diabetic patients to prevent and address skin complications. Successful diabetes skin care includes the prevention, detection, and management of such complications. The main objective is to preserve skin integrity and avert potential issues. This can be accomplished through routine skin examinations, maintaining cleanliness and dryness, steering clear of harsh soaps and detergents, and utilizing suitable moisturizers and emollients.

References:

https://www.cdc.gov/diabetes/health-equity/diabetes-by-the-numbers.html

https://www.who.int/news-room/fact-sheets/detail/diabetes#:~:text=Diabetes%20is%20a%20chronic%20disease,use%20the%20insulin%20it%20produces.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10259731/

Diabetes mellitus is a chronic medical condition characterized by elevated blood glucose, resulting from either insulin deficiency or progressive loss of insulin secretion/insulin resistance. Skin complications are common in individuals with diabetes and can arise due to various factors, including impaired blood circulation, nerve damage, and susceptibility to infections. Some of the prominent skin complications associated with diabetes include diabetic dermopathy, diabetic foot ulcers, acanthosis nigricans, and necrobiosis lipoidica diabeticorum. Skin-related diabetes complications are often a sign of uncontrolled blood glucose and may indicate undiagnosed diabetes or the need for medication regimen adjustment.

Diabetes can lead to micro- and macrovascular complications as a result of prolonged elevated blood glucose levels, i.e., uncontrolled, or poorly controlled diabetes. Microvascular damage to the blood vessels within the skin can lead to inadequate blood supply that manifests as diabetic dermopathy. Diabetic dermopathy typically presents light brown, scaly and oval or circular patches on the skin, usually on the shins. Although diabetic dermopathy itself is harmless and does not require treatment, it may be a marker of more severe complications. Acanthosis nigricans is another condition in which tan or brown, raised areas appear on the skin, usually on the sides of the neck, underarms, groin, hands, elbows, or knees. Overweight patients with diabetes are most likely to be affected by acanthosis nigricans; therefore, the best treatment is weight loss in addition to topical creams to help appearance-wise.  

Microvascular damage to blood vessels can also lead to peripheral neuropathy which can result in reduced sensation and impaired wound healing. Poor blood circulation and neuropathy may lead to the development of ulcers, which manifest as open sores on the feet. Furthermore, due to the reduced sensation or numbness in the feet, individuals with diabetes may not be aware of these ulcers, increasing the risk of complications such as infections. Treatment of diabetic ulcers includes wound care, infection control, and in severe cases, surgical interventions such as revascularization or amputation.

Necrobiosis lipoidica is a rare, chronic skin complication associated with diabetes. Although the exact cause is unknown, proposed theories involve microvascular damage, collagen structure changes within the skin’s blood vessels or inflammation. Necrobiosis lipoidica typically manifests on the lower extremities as raised, red-brown lesions, often with a shiny or atrophic appearance. Ulceration occurs in approximately one-third of necrobiosis lipoidica lesions and is associated with secondary infections and squamous cell carcinoma. Treatment involves topical or systemic corticosteroids to address inflammation, and in some cases, immunosuppressive therapy or surgery may be considered/required.

Regular skin examinations are crucial for early detection of skin complications. Individuals with diabetes, especially those with peripheral neuropathy, should be informed to check for cuts or sores on the skin (and feet) daily. Other prevention measures include wearing well-fitted shoes, moisturizing to prevent dry skin, proper management of minor cuts (clean with soap and water, cover with sterile gauze), and timely appointments with a dermatologist for any major cuts, burns, or infections. Finally, maintaining optimal glycemic control is essential for preventing and reducing the risk of complications associated with diabetes. Preventive measures, regular monitoring, and early intervention are crucial components of managing these and other skin complications, emphasizing the importance of a multidisciplinary approach involving dermatologists, endocrinologists, and other healthcare providers.

References

American Diabetes Association: standards of care in diabetes – 2023 abridged for primary care providers. Clin Diabetes. 2023 Jan;41(1):4-31. https://diabetesjournals.org/clinical/article/41/1/4/148029/Standards-of-Care-in-Diabetes-2023-Abridged-for

David P, Singh S, Ankar R. A comprehensive overview of skin complications in diabetes and their prevention. Cureus. 2023 May;15(5):e38961. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10259731/

de Macedo GM, Nunes S, Barreto T. Skin disorders in diabetes mellitus: an epidemiology and physiopathology review. Diabetol Metab Syndr. 106 Aug;8(1):63. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5006568/

Diabetes and your skin. Centers for Disease Control and Prevention. 2022 Jun. https://www.cdc.gov/diabetes/library/features/diabetes-and-your-skin.html

Duff M, Demidova O, Blackburn S, Shubrook J. Cutaneous manifestations of diabetes mellitus. Clin Diabetes. 2015 Jan;33(1):40-8. https://diabetesjournals.org/clinical/article/33/1/40/31293/Cutaneous-Manifestations-of-Diabetes-Mellitus

Labib A, Rosen J, Yosipovitch G. Skin manifestations of diabetes mellitus [updates 2022 Apr 21]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [internet]. South Dartmouth (MA): MDText.com, Inc. 2000. https://www.ncbi.nlm.nih.gov/books/NBK481900/

Yu Feng Lin & Fawziya Twam

Your skin can tell you more about your body than you may know. Often times the skin will represent what is happening within the body. Some diseases present themselves on to the skin, like warning signs. One disease which has many connections to the skin is diabetes. There have been instances where patients with diabetes remain undiagnosed. However, many times the skin has shown signs of prediabetes and diabetes, but patients may not recognize the signs or know what they mean.

One sign of diabetes seen on this skin is necrobiosis lipoidica. This is a a patch or patches of skin that present themselves in yellow, red or brown. Oftentimes it starts off small with raised pimple-like bumps throughout the area. Left untreated the bumps turn into larger patches and the pimple-like bumps grow larger to form swollen and hard skin. Blood vessels will become visible in that area of skin. The skin will become itchy and painful. Like many skin conditions, there will be flare ups and times where it goes unnoticed. Necrobiosis lipoidica needs to be treated as it can lead to several complications. The most common complication being infections. In some rare instances Necrobiosis lipoidica may become chronic and turn into squamous cell carcinoma. Going to a dermatologist is an important step in treatment. Many times topical corticosteroids, injected corticosteroids and anti-inflammatory drugs are used. Other than treating the necrobiosis lipoidica itself, it is also important to treat the underlying cause, diabetes.

A more common sign of diabetes displayed by the skin is acanthosis nigricans. Many times this is the first sign of diabetes. It is a dark patch or band of velvety feeling skin. This patch of skin is often seen on the back of the neck, armpit and groin area. This happens due to an increase of insulin in the blood. There isn't a treatment for acanthosis nigricans itself, but by getting a diabetes diagnosis and treating your diabetic condition, the skin should lighten over time. Another sign would be shin spots. Shin spots can appear as spots or lines normally on the shins. In some cases they may appear on the arms, thighs and trunk. Both acanthosis and shin spots are not painful or itchy. They are signs from our body and by managing the diabetes it should manage the skin condition.

Not only does the skin change in color and texture, but it can form new growths known as skin tags. Skin tags are growths that hang from a stalk. They are harmless, but they represent too much insulin in the blood. Many times these skin tags will appear on the eyelids, neck armpit and groin area. Skin tags can be removed in a few ways. Most common way is by freezing them with liquid nitrogen and then cutting them off. It may not be necessary to get them removed and depends on the patient's wishes.

Digital sclerosis can be seen in patients with undiagnosed or uncontrolled diabetes. This is when skin thickens and hardens on the fingers and or toes. This leads to the fingers stiffening and becoming more and more difficult to move. Left untreated the stiff skin will spread to the forearms and upper arms. In some cases, the skin can harden around the knees, elbows and ankles. This will further limit one's mobility. In severe cases, controlling your diabetes may not be enough and patients may be referred to physical therapy. It can also affect your senses. This is one of the reasons foot care is emphasized in diabetes. Injuries in the feet many times can go unnoticed because of the skin condition. High blood glucose can negatively impact one's circulation and eventually leads to nerve damage. This leaves the body incapable of healing properly. Improper foot care along with a wound is a common cause for diabetic ulcers. When a wound is not cared for, it will worsen. Many times diabetics neglect to check their feet for wounds, but even if not in pain, diabetics must regularly inspect themselves for wounds. Their nerve damage may mask a current wound and it won't be noticed until it becomes worse.

With all the possible skin injuries that can take place, infections are a great concern in diabetics. Any time skin feels hot, swollen or painful it may be a sign of infection. There are times that the skin may blister or produce a white discharge. Skin infections may take place in any area of the body. In diabetics whose nerves have been damaged, skin infections may not be noticed right away. It is important to inspect the body and care for any open wounds. If an infection is suspected it must be treated right away.

In rare cases large blisters may appear on a diabetic's skin. These blisters tend to appear suddenly and may look similar to a burn. Oftentimes the blister would be on the hands, feet, legs or forearms. These blisters are not painful and may appear as one large blister or multiple in the same area. The condition is called bullosis diabeticorum.

Our skin represents what is happening on the inside of our body. Listening to some of the signs discussed can help an undiagnosed diabetic get diagnosed or an uncontrolled diabetic regain control. Listening to the signs can save a person from an infection.

References:

Diabetes: 12 warning signs that appear on your skin. American Academy of Dermatology. (n.d.). https://www.aad.org/public/diseases/a-z/diabetes-warning-signs

The NCBI Handbook - NCBI Bookshelf - National Center for Biotechnology ... (n.d.). https://www.ncbi.nlm.nih.gov/books/NBK143764/

Necrobiosis Lipoidica Diabeticorum. ucsfhealth.org. (2020, October 6). https://www.ucsfhealth.org/medical-tests/necrobiosis-lipoidica-diabeticorum

Diabetes and Skincare

Diabetes is a disease in which there are high blood glucose levels in an individual who produces little to no insulin or is insulin resistant. Insulin is a hormone produced by the beta cells in the islets of Langerhans of the pancreas. It functions to regulate blood sugar by allowing muscle, adipose tissue, and liver cells to absorb glucose from the blood which can be converted into energy needed to carry out cellular processes or into fat as storage. After the pancreas secretes insulin and enters the bloodstream, it is distributed to hepatocytes in the liver, which store glucose in the form of glycogen. Likewise, glucose is also taken up by skeletal muscle cells and adipocytes, all of which contribute to lowering glucose concentration in the bloodstream. Diabetic individuals have poor insulin production or insulin resistance; if left untreated, it can lead to many health consequences such as kidney damage, eye damage, and an increased risk for heart disease or stroke. Diabetic symptoms include frequent urination, thirst, weight loss, blurry vision, increased occurrences of infections, and tingling of the hands or feet. Due to excess glucose levels, the kidneys overwork to filter glucose from the blood. The remaining excess glucose is excreted into urine, which brings along fluids from the tissues, thus leading to frequent urination, dehydration, and increased thirst. Further, weight loss ensues as the body burns fat and muscle for energy to compensate for poor glucose (which is fuel for the body) uptake by cells.

There are two types of diabetes: Type 1 and Type 2. Type 1 diabetes occurs when the body’s immune system attacks and destroys cells in the pancreas responsible for making insulin; consequently, the pancreas ceases to make insulin. Type 1 diabetes usually is seen in children and adolescents. On the other hand, Type 2 diabetes is more common than type 1, and occurs when the pancreas does not produce enough insulin or does not use insulin well. Type 2 diabetes usually develops in middle-aged to older populations, however, can occur at any age. Both types can lead to dermatologic skin conditions, such as acanthosis nigricans, diabetic dermopathy, and bullosis diabeticorum. In acanthosis nigricans, dark patches or bands of velvety skin appear in skin creases, which include the neck, armpits, or groin. Development of acanthosis nigricans is an indication of insulin resistance and may be a prediabetic symptom typically seen in obese individuals. To treat acanthosis nigricans, weight management with a healthy diet and a physically active lifestyle is the most optimal approach. Further, it is important to address diabetes with pharmacological management when appropriate. On the other hand, diabetic dermopathy is characterized by light brown, scaly patches that are oval or circular in nature and are often mistaken for age spots. It occurs in up to 30% of patients with diabetes, and is prominent in older patients or those who have had diabetes for ten to twenty years. They commonly appear on the front of both legs. These markings are harmless, painless, and do not need treatment. It tends to resolve independently after a few years following improved blood glucose control. Another skin condition affecting diabetic patients is bullosis diabeticorum, also known as diabetic blisters. They appear on the backs of fingers, hands, toes, feet, and occasionally the legs or forearms, and are large and painless. It is more common in men than women and is prevalent between populations of 17 to 84 years of age. These blisters range from 0.5 to 17 centimeters in size and are of two types: intraepidermal bullae and subepidermal bullae. Intraepidermal bullae are filled with a clear, viscous fluid and may take 2 to 5 weeks to heal without scarring and atrophy. Subepidermal bullae are filled with blood and the healing process may result in scarring and atrophy. Treatment requires management of blood glucose levels and ensure that the blister remains unbroken to avoid secondary infection.

Managing diabetes with pharmacological and nonpharmacological measures is crucial in the prevention of worsening health complications and dermatologic conditions. It is important to inform and educate diabetic patients to keep their skin clean and dry as high glucose levels impair the body’s ability to fight infection. Further, diabetic individuals are prone to having dry skin, which may cause scratching and itching and is a gateway for skin infections; therefore, avoiding hot baths and showers is ideal as well as using moisturizing soaps and lotions daily.

References

“Diabetes and Skin Complications.” Diabetes and Skin Complications | ADA, diabetes.org/diabetes/skin-complications. Accessed 7 June 2023.

“Diabetes and Your Skin.” Centers for Disease Control and Prevention, 14 June 2022, www.cdc.gov/diabetes/library/features/diabetes-and-your-skin.html#:~:text=Dry%2C%20itchy%20skin&amp;text=But%20dry%2C%20itchy%20skin%20can,can%20make%20your%20skin%20dry.

“Skin Problems Associated with Diabetes Mellitus.” DermNet, dermnetnz.org/topics/skin-problems-associated-with-diabetes-mellitus. Accessed 7 June 2023.

“Type 2 Diabetes - NIDDK.” National Institute of Diabetes and Digestive and Kidney Diseases, www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/type-2-diabetes. Accessed 7 June 2023.

Diabetes and skincare

The diagnosis of diabetes comes with many risks including diabetic foot syndrome. This is the ulceration of the foot distally from the ankle. It involves neuropathy which is numbness or weakness and infection. Abnormal foot pressures and peripheral neuropathy are causes for diabetic foot syndrome. Peripheral neuropathy is nerve damage that makes the foot vulnerable to excess pressure and damage. This also causes excess foot dryness and cracking which can leave the skin vulnerable to the passage of pathogens. Diabetic foot ulcerations are the most common cause of hospitalization for diabetic patients. The lifetime risk of diabetic foot infections for patients with diabetes is 25%. Within four years, the majority of these patients will need an amputation. Following amputation, the five year mortality risk is 39-68% (Volmer-Thole, M., & Lobmann, R). Risk factors include the patient's age, previous ulcers, and sensorimotor diabetic polyneuropathy. Ulcers form due to the lack of pain sensation in the feet. Injuries can go unnoticed longer in these patients leading to more serious outcomes. Motoric neuropathy is also seen with loss of muscles changing the position of toes. This changes the load on the foot and causes hyperkeratosis. Foot ulcers are circular wounds with hyperkeratotic borders. Diabetes causes impaired wound healing by cellular alterations. There is reduced inflammatory reactions, microcirculation disturbances, reduced fibroblast proliferation, and a reduced cytokine-protease profile (Volmer-Thole, M., & Lobmann, R).

Furthermore, foot ulcerations increase the risk of cardiovascular morbidity. There is a 2-4 times higher rate of cardiovascular morbidity and mortality in diabetic patients compared to non-diabetic patients (Tuttolomondo, A., Maida, C., & Pinto, A.). There is also a 2 times mortality rate of cardiovascular disease of diabetic patients with foot infections compared to diabetic patients without foot infections (Tuttolomondo, A., Maida, C., & Pinto, A.). A study was conducted on cardiovascular disease in diabetic patients with and without foot ulceration. It was determined that CAD is the most common cause of death related to cardiovascular disease in patients with amputations. Another result of the study displayed that patients with foot complications had increased prevalence of cardiovascular risk factors including: hypercholesterolemia, LDL plasma levels > 130 mg/dL, high triglycerides, and microalbuminuria/proteinuria (Tuttolomondo, A., Maida, C., & Pinto, A.). Hypertension is another common comorbidity in patients with type I and type II diabetes and is a major risk factor for atherosclerosis. It increases risk of vascular diseases like diabetic retinopathy, nephropathy, and peripheral vascular disease.

Coexisting infections in patients with diabetic foot syndrome increase the risk of amputation due to the possibility of infecting deeper into tissue or even the bone. The presence of infection can be determined if the wound is purulent or inflamed. The IDSA classification system can be used to assess the severity of an infection.

Triggers include damage from walking barefoot or cutting nails. Protection of the feet is important while walking. When there is an infection present, it must be treated quickly with antibiotics and cleansing of the wound. Removal of dead tissue is necessary to promote wound healing. A non-occlusive and moist therapy for the wound is recommended.

Diabetic foot syndrome is a common development for patients with diabetes. Patients must watch for signs of peripheral neuropathy and be careful to avoid injury to their feet. Injury to the feet can quickly progress to an ulcer and infection that must be treated promptly.

Resources:

Tuttolomondo, A., Maida, C., & Pinto, A. (2015). Diabetic foot syndrome: Immune-inflammatory features as possible cardiovascular markers in diabetes. World journal of orthopedics, 6(1), 62–76. https://doi.org/10.5312/wjo.v6.i1.62

Volmer-Thole, M., & Lobmann, R. (2016). Neuropathy and Diabetic Foot Syndrome. International journal of molecular sciences, 17(6), 917. https://doi.org/10.3390/ijms17060917

Written by Aleksandra Agranovich

Type 1 Diabetes

· Result of an autoimmune beta-cell destruction, leading to absolute insulin deficiency

· Accounts for 5-10% of all DM cases

· Prevalence: ~ 3 million in US

· Highest ethnicity rate: Caucasian

· Dependent on exogenous insulin to sustain life

· Diagnosis can be made at any age

· 70% of the time, happens before age 30

Signs and Symptoms

· Children: Diabetic ketoacidosis, nocturia enuresis, polyuria, polydipsia, weight loss

· Adults: polyphagia

Other symptoms: blurred vision, drowsiness, poor stamina, nausea/vomiting, skin and bladder infections, vaginitis in females

Type 2 Diabetes

· A metabolic disorder characterized by hyperglycemia due to insulin resistance

· Deficiency of pancreatic beta cell function

Signs and Symptoms:

· Polyuria

· Polydipsia

· Polyphagia

· Risk Factors: Heredity, overweight/ obesity, physical inactivity, age, high-risk ethnic population, smoking, gestational DM, HTN/HLD/CVD, PCOS, chronic glucocorticoid consumption, 2nd generation antipsychotics, sleep disorders

Approach to treating Type 2 DM

Healthy eating, being active, taking medication, monitoring (glucose, stress levels…etc), problem solving, healthy coping, reducing risks

Diabetic Peripheral Neuropathy & Foot care

Most diabetic patients experience foot ulcers and dry skin due to diabetic neuropathy. This condition is completely preventable but can lead to infection and morbidity. Diabetic neuropathy is a type of nerve damage that occurs when high blood glucose levels injure nerves throughout an individual’s body.

Ways to Prevent Diabetic Neuropathy and Foot Ulcers

• Inspect your feet daily

• Wash your feet daily!

• Cut nails carefully & never treat corns or calluses yourself

• Wear clean, dry socks and change them daily

• Consider socks made for diabetics

• Shake out your shoes and feel the inside before wearing

• Never go barefoot

• Keep feet warm & dry

• Optimize blood sugar control to slow progression

• Treat with pregabalin, duloxetine, or gabapentin

• Annual foot evaluation to identify risk for ulcer/amputation

Signs and Symptoms of Diabetic Neuropathy

• Numbness or reduced ability to feel pain or temperature changes

• Tingling or burning sensation

• Sharp pains or cramps

• Increased sensitivity to touch

• Serious foot problems (ulcers, joint problems, etc)

Resources

Bandyk, Dennis F. “The diabetic foot: Pathophysiology, evaluation, and treatment.” Seminars in vascular surgery vol. 31,2-4 (2018): 43-48. doi:10.1053/j.semvascsurg.2019.02.001

Reardon, Rebecca et al. “The diabetic foot ulcer.” Australian journal of general practice vol. 49,5 (2020): 250-255. doi:10.31128/AJGP-11-19-5161

Natalie Eshaghian & Donna Salib

Diabetes & Skincare

Diabetes mellitus is a disease where the body is unable to produce insulin causing the body to be unable to break down and metabolize glucose, fat, and protein in the body. Diabetes is known to have many side effects with its disease, however, a serious side effect is its skin side effects. It has been found that dermatological reactions have been associated with an adverse effect of diabetes. These skin dermatoses are noninfectious and are markers of either poor glycemic control shown by lesions, or autoimmunity manifestations represented by cluster skin alterations. (1)

Diabetes is found to have many signs and symptoms of the disease, including things like frequent urination, excessive thirst and hunger, and tingling and numbness of the hands and feet. However, another sign and symptom of diabetes is the manifestation of dry skin. Excess sugar in the body ends up in the urine and along with this, takes fluids from other tissues including the skin which causes it to become drained of fluids, dry, and itchy. In a study done, it was found that dermatoses were more common in the diabetes group tested over the non-diabetic control group. (2) It was seen that skin infection was the most common type of skin reaction, followed by acanthosis nigricans, which is characterized by velvet dark patches found on the folds and creases of the body, and lastly xerosis was seen as well, which is rough dry scaly skin. (2) Dry skin is a common side effect of many diseases and environmental factors, such as colder weather and eczema. The issue is, that many patients may develop this dry skin symptom earlier on in their diabetes diagnosis, and it can act as an early sign of the disease, but many do not know and will look past the feature and won't seek the necessary treatment.

With the appearance of dry skin from diabetes mellitus comes the involvement of the microvasculature, extravascular dermal matrix, dermo-epidermal junction, epidermis, sweat glands, hair follicles, and the hypodermis. (1) This involvement erupts complications in reference to those layers and segments of the skin so it is important for people with diabetes to take care of their skin because with the temptation to scratch these vulnerable dry patches there is the chance of developing a cut which is especially dangerous for a person with high blood sugar. A cut in the skin makes it incredibly hard for a diabetic to heal due to the great amount of sugar present in the blood, hindering blood elasticity which makes blood vessels more narrow, and this reduces the supply of blood and oxygen to the site of the wound, therefore, allowing the cut not to heal properly. (3) This could ultimately lead to a significant infection which can lead to complications since people with diabetes are vulnerable to a weakened immune system and are already more prone to infections.

Acanthosis nigricans is a type of skin condition that presents itself in dark patches of skin with a velvety texture, These patches usually appear in areas where the skin creases or folds on the neck, elbows, behind the knees, on the knuckles, or in the armpits. This skin condition is associated with the process of hyperkeratosis which includes a few signaling pathways that play a role in this. Any increase or misutilization of insulin from the insulin-like growth factor receptor can lead to the proliferation of keratinous sites or dermal fibroblasts leading to hyperkeratosis. Signaling with the fibroblast growth factor receptor can be involved as well as there can be a mutation in the receptor leading to hyperactivation of this receptor and proliferation of dermal fibroblasts. Patients with this skin condition usually want treatment for cosmetic purposes and can be the first thing they notice that allows for the diagnosis of diabetes. The goal is to treat the root cause of this condition which would be insulin resistance in some cases.

High blood sugar not only increases inflammation in cuts and sores but leads to poor circulation, making it hard for blood to reach and repair damaged areas of the skin. It’s not uncommon for patients with diabetes to develop foot sores that can lead to even more serious problems, leading to spreading from the wound to the bone and therefore in some cases requiring amputation. It is vital for patients to regularly see a podiatrist in order to monitor any infections that may arise and prevent any from occurring by maintaining their cleanliness such as trimming the toenails. Some patients can have ulcers in their feet and not even notice them, so the motto “prevention is better than cure” is very meaningful in this case. Overall, people often neglect the complications diabetics have in reference to their skin. Not only is this significant due to it being an indicative sign of the disease, but, these skin diseases can make life for patients with diabetes more complicated. This vulnerability to cuts and wounds can hinder diabetics from sports or exercise in fear of infection or inability to heal and ultimately impacts the choices they make to improve their health. Additionally, with a recurring skin condition such as acanthosis nigricans, this can impact a patient’s social life due to possible insecurity of these dark patches of skin. In general, the apparent skin drawbacks that come with diabetes are significant and should definitely be discussed and monitored.

References:

1. Piérard GE, Seité S, Hermanns-Lê T, Delvenne P, Scheen A, Piérard-Franchimont C. The skin landscape in diabetes mellitus. Focus on dermocosmetic management. Clin Cosmet Investig Dermatol. 2013;6:127-135. Published 2013 May 15. doi:10.2147/CCID.S43141

2. Timshina DK, Thappa DM, Agrawal A. A clinical study of dermatoses in diabetes to establish its markers. Indian J Dermatol. 2012;57(1):20-25. doi:10.4103/0019-5154.92671

3. Rosenberg CS. Wound healing in the patient with diabetes mellitus. Nurs Clin North Am. 1990;25(1):247-261.

Thank you Natalie for your post. In reference to the following: Do you feel NDL may have a correlation with estrogen &/or other hormones?

"NLD is a rare condition that effects mostly women."

Only answer should you care to do so, not a requirement.

Diabetes and Skin Care

Diabetes Mellitus is a metabolic disease which causes high blood sugar. Insulin is a hormone that moves sugar from your blood into your cells to be stored or used for energy. With type 1 diabetes, it is an auto immune disease which attacks and destroys cell in the pancreas, where insulin is produced. Type 1 diabetes is often found in younger individuals and is rare making up only 10% of the patient population. Type 2 diabetes is way more common and occurs when your body becomes insulin resistant. Insulin resistance cause blood glucose levels to rise since they are not being transported into the cells. While there are many ways to test your blood sugar, and manage your diabetes, if left unmanaged, the high blood sugar can cause damage to nerves and other organs, including the skin.

Since diabetes weakens the body’s immune system through decreasing neutrophil production, reducing T lymphocyte numbers and repressing humoral immunity mediations, it makes a patient more prone to bacterial infections including styes, boils, and infections around the nails. Other skin related conditions consist of acanthosis nigricans, diabetic dermopathy and, necrobiosis lipodica diabeticorum. Acanthosis nigricans is a condition where tan or brown raided areas appear on the sides of the neck, armpits, and groin. The best treatment is to lose weight (eat healthy, exercise etc.). Diabetic dermopathy is a result of changes in the small blood vessels. Dermopathy often look like light brown scale patches which get mistaken for age spots. This disorder affects the front of the legs and there is no treatment. Necrobiosis lipoidica diabeticorum (NLD) is another disease caused by changes in blood vessels. Unlike dermopathy, these spots are fewer, larger, and deeper. Additionally, these spots can be itchy, painful, and crack open. NLD is a rare condition that effects mostly women.

To prevent these diseases from occurring, good skincare is essential. 1st, managing your diabetes is the most important. Patients with untreated glucose levels tend to have dry skin and less ability to fend off harmful bacteria, increasing risk of infections. It is important to keep the skin clean and dry. Avoid hot bath and showers, use moisturizing soaps and skin lotions. However, do not put lotions between the toes as the access moisture can cause fungus growth. Treat cuts right away. Wash minor cuts with soap and water. Only use antibiotic cream or ointment when needed. Finally take good care of your feet. Wash your feet thoroughly every day, and do not forget to dry between your toes trim your toenails and make sure to file down sharp edges. Check your feet for sores, cuts, blisters, or redness daily. Wear moisture wicking socks and comfortable shoes. Try and avoid walking barefoot.

References:

“Caring for the Diabetic Foot.” Dermatology Times, www.dermatologytimes.com/view/caring-diabetic-foot.

“Foot Complications.” Foot Complications | ADA, www.diabetes.org/diabetes/complications/foot-complications.

“Skin Complications.” Skin Complications | ADA, www.diabetes.org/diabetes/complications/skin-complications.

Patients with diabetes commonly suffer from cutaneous infections, dry skin, and pruritis. Although these skin disorders may seem harmless and can happen to anyone, they are notably more severe in DM patients as the resulting outcomes include skin lesions that can evolve into ulcerations and conditions like diabetic foot. Source 3 discusses multiple studies on skin disorders in DM patients and determines that they are highly correlated with glycemic control. Note – “As an example, Foos et al. conducted a study with 403 DM patients in Brazil and evaluated their skin disorders and glycaemia control. Thus, the study demonstrated that 94 % of patients with inadequate glycaemia control had some skin disorder; on the other hand, only 60 % of DM patients with adequate glycaemia control had some skin disorder.” Early stage skin disorders in DM such as xerosis, callus, and fissues, are usually neglected and frequently underdiagnosed. It’s important for pharmacists to ask the right questions as most patients might not even realize they have a skin disorder. Regular consultation sessions to ensure the patient understands how to properly manage their DM and usage of skincare to avoid disorders that can worsen and lead to neuropathy, ulcers, or even amputation in severe cases. Patients should be educated on how to examine their extremities on a routinely basis. This is important as they might be injured and not be able to feel it. These lesions can become infected, leading to necessary amputation. Moisturize your feet but not your toes. Wear clean and dry socks, changing them daily after washing in lukewarm water. Seek assistance from a family member or home aid if you feel corns or calluses. Skin serves as our first line of defense, our physical barrier that shields us from the environment and simple patient education can help avoid many cases.

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658433/

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5312172/

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5006568/

Patients with diabetes are at a higher risk of foot ulcers and amputations due to disease complications such as diabetic neuropathy and peripheral artery disease. These patients are at a higher risk of fungal and bacterial infections, particularly in the feet, and if left untreated, they can lead to the loss of the limb. Diabetes can lower the amount of blood flow to the feet, decreasing the body’s ability to fight off and heal infections. This is why it is recommended for all diabetic patients to see a health care provider at least annually for a comprehensive foot evaluation. Some daily skincare tips for healthy feet include washing the feet with warm water, checking for any skin or nail changes, and trimming the toenails properly. When washing the feet, do not use hot water or soak them because doing those can actually dry out the feet. After drying the feet completely, use lotion on the top and bottom while avoiding the areas in between the toes (moisture in that area can lead to fungal infections). Moisturizing prevents the skin from being dry and cracked, and more prone to infection. Toenails should be trimmed straight across with any sharp edges filed down and avoid cutting the skin. When examining the feet, take note of any cuts, calluses, redness, swelling, blisters, sores, corns, or any other changes to the skin and nails. These can make the skin more prone to infection if not properly addressed right away. It is also best to avoid being barefoot both inside and outside to avoid injury to the feet and infections. If there are corns or calluses on the feet, consult a podiatrist or other health care practitioner before taking a pumice stone and smoothing them down. These are just some of the basic skincare tips for diabetic patients and they should refer to their health care provider if they have concerns about possible infections in the feet to get those treated immediately.

References:

1. American Diabetes Association. 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(Suppl 1):S135-S151. doi:10.2337/dc20-S011

2. Diabetes and your feet. CDC. https://www.cdc.gov/diabetes/library/features/healthy-feet.html. Updated December 4, 2019. Accessed April 6, 2021.

3. Diabetes and foot problems. NIDDK. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/foot-problems. Updated January 2017. Accessed April 6, 2021.

Skin care is important in patients who are diagnosed with diabetes. Diabetic patients are more prone to having foot ulcers and impaired wound healing which can lead to serious infections and amputations. As more people become diagnosed with diabetes each year, the incidence of diabetic foot disease will increase as well. One way that can help discover the risk of diabetic foot disease is observing diabetic patients and their increase in inflammatory cell infiltration and the density of blood vessels. These microscopic changes may present with surface level changes in the skin and may better help with the idea of wound healing in diabetic foot ulcers.

There are histological changes that occur in the skin of diabetic patients: loss of elasticity, increased thickness, and clumping of elastic tissue. Elastic fibers in the skin tend to be destroyed and separated causing the skin to lose its foundation and anchoring to the basement membrane. The increased thickness of the skin will cause inflexibility and may increase the risk of damage even if caused by minor injury. Some of these changes may be due to the lack of blood flow to the skin in lower extremities such as the feet. Some of these changes to the skin can permeate down to the blood vessels. The vessel changes caused by diabetes are similar to the vascular changes caused by ultra-violet light and aging. However, diabetic changes to the skin are found in areas that are not exposed to UV light such as the buttock, thighs, and feet.

Inflammation can also occur right under the surface of the skin. Typically, patients who have type 2 diabetes and obesity have an increased level of inflammatory cytokines circulating throughout the body compared to patients who do not have these two conditions. Both diabetes and obesity are considered inflammatory conditions. In patients who are obese, inflammation occurs in the adipose tissue and expression of TNF alpha is increased. Furthermore, the expression of tumor necrosis factor alpha reduces after weight loss. This information further solidifies the connection between the risk factors of obesity to the inflammation pathway resulting in type 2 diabetes. Animal studies have shown elevations in inflammatory cytokines detected in the dermis of the skin around the hair follicles and blood vessels. However, this systemic reaction of inflammatory cytokines is associated only with diabetic patients who present with neuropathy. Furthermore, elevation in endothelial cells can be seen proliferating around the site of new blood vessels forming, however, this has no affect on the blood flow to the skin. The reason for this may be because inflammation can stimulate angiogenesis. Animal studies have also shown that the density of blood vessels in the skin have also increased in diabetic models. Across all the diabetic animal models, skin inflammation has been the dominant factor. Thus, leading to other ways to detect diabetes in patients.

References

Tellechea, A., Kafanas, A., Leal, E. C., Tecilazich, F., Kuchibhotla, S., Auster, M. E., Kontoes, I., Paolino, J., Carvalho, E., Nabzdyk, L. P., & Veves, A. (2013). Increased skin inflammation and blood vessel density in human and experimental diabetes. The international journal of lower extremity wounds, 12(1), 4–11. https://doi.org/10.1177/1534734612474303

Dandona, P., Aljada, A., Chaudhuri, A., Mohanty, P. (2004). Endothelial Dysfunction, Inflammation, and Diabetes. Review in Endocrine & Metabolic Disorders, 5, 189-197.

Goodfield, M.J.D., Millard, L.G. The skin in diabetes mellitus. Diabetologia 31, 567–575 (1988). https://doi.org/10.1007/BF00264762

Diabetes is a very common chronic disease state that affects many in the population today, especially in the United States. Those with increased risk are those with family history of diabetes, obesity, African American, Asian or Hispanic race and those with poor lifestyle habits like smoking or lack of exercise. Diabetes can have effects on the skin because of the macrovascular and microvascular effects. Neuropathy causes a patient to lose sensation in their extremities, particularly in the feet in patients with diabetes. To prevent complications that involve the feet, diabetes patients are recommended to visit a podiatrist yearly. Diabetes patients are also recommended to take care of their feet and monitor them regularly to make sure there are not any open wounds or cuts on the feet that could get infected. It may also be beneficial for these patients to get pedicures regularly in order to fully keep the feet clean. With the loss of sensation on the feet it is critical for the patients to get shoes that are not too tight fitting that can cause the area to become bruised and deoxygenated. This is why an annual foot exam is necessary to test for any loss in sensation of the feet. Diabetic complications also include various parts of the skin causing reactions. This includes diabetic dermopathy, diabetic blisters and digital sclerosis. Diabetic dermopathy is not harmful and does not need treatment but causes skin changes. It is the presence of dark brown scaly patches that occur on the skin from the changes in small blood vessels of the microvasculature. Thick waxy skin can develop on the back of a diabetes patients’ hands. This is Digital sclerosis. This is due to the uncontrolled blood glucose levels and this also cannot be treated. The blood glucose must go down in order to control this condition, that is the only way to treat it. Diabetic blisters are rare in patients with diabetes. Blisters can occur on the backs of fingers, hands, toes feet and sometimes on legs or forearms. The sores look like burn blisters and most commonly occur in those that are experiencing neuropathy. These blisters usually heal on their own and are painless with no redness around them. The healing process usually takes about 3 weeks and the only treatment is to treat the high blood glucose. It is highly recommended for these diabetes patients to keep their skin moisturized and prevent dry skin. Dry skin can cause itchiness on the skin’s surface causing an increased likeliness of opening the skin and creating open wounds due to itching. Itching can also be caused by poor circulation. Itching may be self-treated. It is recommended to use mild soap with moisturizer upon bathing and limiting bathing when humidity is low in the area. Stys, boils, folliculitis, carbuncles and infections around the nails can all be present as bacterial infections in people with diabetes. Fungal infections from Candida albicans as the culprit are common in diabetes patients. The fungus creates itchy rashes of moist, read areas that can be surrounded with blisters and scaly skin. This most commonly occurs in areas that are moist due to sweating or keep moisture entrapped due to the enfolding of the skin like under the breasts, around the nails, between the fingers and toes, corners of the mouth, under the foreskin in uncircumcised men and in the armpits and the groin.

Reference:

https://www.diabetes.org/diabetes/complications/skin-complications

The three main types of diabetes are type 1 diabetes, where the body lacks the production of insulin and type 2 diabetes, where the body is insulin resistant and gestational diabetes. There are several physical indications of diabetes. Some key signs and symptoms are increased thirst, increased urination, increased appetite, unexpected weight loss, dry skin, and increased infections. If your diabetes is undiagnosed or uncontrolled you may start to see appearances on the skin. There are many conditions that may appear on the skin such as necrobiosis lipoidica, granuloma annulare, acanthosis nigricans and diabetic dermopathy. For necrobiosis lipoidica, the skin may have small raised bumps that look like pimples. As the condition progresses, it may become swollen or hard patches. Granuloma annulare is when the bumps and patches on the skin appear to be red, pink or bluish purple. Acanthosis nigricans can appear around the neck, armpit, groin or other areas where the skin becomes darker and may have a velvet feel. This indication means there is too much insulin in the body. Diabetic dermopathy is usually found around the shins. It appears as spots or lines that create a mild depression on the skin. This condition is often mistaken for age spots. The spot may fade or remain permanently on the skin.

Skin care management is important for diabetic patients to prevent infections. Common infections for diabetic patients are urinary tract infections, skin infections, ear infections, nose infections, and throat infections. Most patients have difficulty in healing their infections or require a longer time to heal due to the reduced blood flow in parts of the body. Prevention of infections require a healthy lifestyle, exercise, vaccinations, hand hygiene, and comfortable footwear. Diabetics are hospitalized 15% to 20% due to diabetic foot infections. Diabetic foot infections can range from local fungal infections to life threatening infections. If unmanaged the infection may require invasive procedures. Depending on the severity of the infection, management of diabetic foot infections may require antibiotic therapy, debridement, drainage, tissue removal, and in some severe cases amputation. Routine foot checks are required especially for those that have already had foot ulcers or infections. Most patients are likely to have a recurrence of infection. Overall goal for diabetic patients is to prevent infections and preserve the integrity of the foot.

Cancer patients that also suffer from diabetes are at even higher risk for infections. As the patient's immune system is suppressed by chemotherapy, the body is more prone to infections. Chemotherapy has many side effects that can impact the skin. Depending on the diagnosis and chemotherapy treatment, patients can have increased infections in certain areas of the body and this may be extremely difficult to manage with other pre-existing conditions. Patients on taxanes such as docitaxel or pacitalxel are likely to experience onycholysis or nail infections which leave them at a higher risk for developing a diabetic foot infection. The key is to routinely check the foot for ulcers and wear appropriate shoes that promote blood circulation.

1. Adams CA Jr., Deitch EA. Diabetic foot infections. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: https://www.ncbi.nlm.nih.gov/books/NBK6985/

2. Giovannucci E, Harlan DM, Archer MC, et al. Diabetes and cancer: a consensus report. Diabetes Care. 2010;33(7):1674-1685. doi:10.2337/dc10-0666

3. Diabetes: 12 warning signs that appear on your skin. (n.d.). Retrieved September 01, 2020, from https://www.aad.org/public/diseases/a-z/diabetes-warning-signs

4. Diabetes, infections, and you. (n.d.). Retrieved September 01, 2020, from https://apic.org/monthly_alerts/diabetes-infections-and-you/

Diabetes, whether it is immune-mediated (type 1) or end-organ insulin resistant (type 2), is a major metabolic condition that afflicts a disproportionate amount of the population. It is a leading cause of morbidity and mortality, further complicated by micro and macrovascular dysfunctions. The glucose dysregulation that is typical of diabetes can sometimes present with skin changes, even with adequate glycemic treatment.

Non-infectious dermatoses in diabetes have been shown to be useful as markers in early stages of the disease - even in the absence of a clear diagnosis. Necrobiosis lipoidica associated with type 1 diabetes mellitus (T1DM) initially presents as small, solid bumps resembling pimples and later progresses into patches of swollen, hard skin. Treatment generally consists of steroids and other immunosuppressive agents. Steroids carry significant risk in diabetic patients, as they may further cause glucose dysregulation. Acanthosis nigricans associated with type 2 diabetes mellitus (T2DM) are usually present in the creases of the neck and is often the first diabetic-related skin condition to occur. Treatment of acanthosis nigricans consists of treating the underlying cause and encouraging weight loss. Topical or systemic retinoids may be useful in symptomatic relief. Digital sclerosis typically occurs in poorly controlled diabetes or in resistant diabetes. The skin on the peripheries becomes waxy, tight, and stiff to move. Eruptive xanthomas often present as yellow papules with an erythematous base on the buttocks, elbows, and knees. It is directly related to poor triglyceride control, which often occurs in conjunction with poor glycemic control. Treatment of eruptive xanthomas typically consists of lowering triglyceride levels. Diabetic dermopathy, also known as shin spots, are easily mistaken for age spots, but are another way of recognizing patients with poor glycemic control. It is asymptomatic and harmless so no treatment is needed. More common diabetes-related skin conditions like dry skin, xerosis, and acquired ichthyosis often present at the shins and feet.

Diabetes also naturally predisposes the body for skin infections, especially in uncontrolled diabetes. Not only does hyperglycemia create a better environment for bacteria and fungi to propagate in the body, diabetes naturally disturbs the body’s immune and hormonal systems. Diabetes suppresses the immune system through decreasing neutrophil function, reducing T lymphocyte numbers, and repressing humoral immunity mediators. Peripheral neuropathy, another microvascular complication of diabetes, can also lead to skin infections. As a result of nerve damage and poor circulation, especially in the lower extremities, patients often lose feeling in the affected limbs and are less likely to notice a cut, bruise, or any kind of bleed. These injuries, if not promptly noticed and addressed, are prime locations for infectious pathogens. It is the reason why diabetic patients are recommended to go to their podiatrists annually.

The fungal candida family, especially candida albicans, are usual culprits in diabetic skin infections, often infecting the vaginal mucosa, perineum and perianal area, the oral mucosa, and skinfolds.

References

1. Caring for the diabetic foot. Dermatology Times. https://www.dermatologytimes.com/view/caring-diabetic-foot. Accessed July 1, 2020.

2. Mendes AL, Miot HA, Junior VH. Diabetes mellitus and the skin. Anais Brasileiros de Dermatologia. 2017;92(1):8-20. doi:10.1590/abd1806-4841.20175514

3. Duff M, Demidova O, Blackburn S, Shubrook J. Cutaneous Manifestations of Diabetes Mellitus. Clinical Diabetes. 2015;33(1):40-48. doi:10.2337/diaclin.33.1.40

4. Diabetes: 12 warning signs that appear on your skin. American Academy of Dermatology. https://www.aad.org/public/diseases/a-z/diabetes-warning-signs. Accessed July 1, 2020.

5. Pierard G, Seite S, Hermanns-Lê T, Delvenne, Scheen A, Pierard-Franchimont. The skin landscape in diabetes mellitus. Focus on dermocosmetic management. Clinical, Cosmetic and Investigational Dermatology. 2013:127. doi:10.2147/ccid.s43141

Written by: Denise Cotter and Niyati Doshi

This presentation discussed information related to diabetes and skin care along with a correlation to sleep and how sleep affects skin conditions that may appear. This presentation specifically focuses on type 2 diabetes mellitus, which can be either genetic or due to environmental factors. Diabetes is estimated to affect 425 million people around the world and is more prevalent in certain populations, such as Asians, Hispanics, American Indians/Alaska Natives, and African Americans. The risk for type 2 diabetes is greater in those who have both a paternal and material history and is mediated via genetic, anthropometric (BMI, waist circumference), and lifestyle choices (diet, physical activity, smoking). Sleep duration is also another factor, which relates in both quantity and quality of sleep. In comparison to sleeping for 8 hours, those who slept ≤ 5-6 hours or >8-9 hours per night were associated with an increased risk for type 2 diabetes. Another possible cause is disruption of sleep, in which melatonin secretion is affected and can possibly lead to an increased risk of type 2 diabetes. Some categories of sleep disturbances that can be a cause of type 2 diabetes include alteration of sleep durations, chronic sleep restriction, excessive sleep, alterations in sleep architecture, sleep fragmentation, and circadian rhythm disorders and disruption. Lack of sleep or a disruption can affect health, mood, and quality of life. This can alter how one behaves or acts and can in turn be an environmental factor leading to an increased risk for type 2 diabetes.

There are many skin manifestations that are related with diabetes mellitus (DM). Acanthosis nigricans (AN) is a dermatologic manifestation of DM that presents as multiple poorly demarcated plaques with grey to dark brown hyperpigmentation and a thickened velvety verrucous texture. It is more commonly seen in those with type 2 DM and those with a darker skin color. It is usually found in body folds, such as the neck, armpits, groin, naval and other areas. While the pathogenesis of AN is not completely understood, theory states that hyperinsulin activates insulin growth factor receptors (IGF), specifically IGF-1, on keratinocytes and fibroblasts, thus causing cell proliferation. Diabetic dermopathy (DD), also known as shin spots or pigmented pretibial patches, is seen in as many as one-half of those with diabetes. It presents with round, dull, red papules, and slowly progresses into well-circumscribed, atrophic, brown macules with a fine scale. Lesions can dissipate over time and may leave behind an area of hyperpigmentation. DD is a clinical diagnosis and it should not require a skin biopsy when present. Diabetic foot syndrome includes both neuropathic and vasculopathic complications in those with DM. This attributes to morbidity, mortality, hospitalization, and reduction in quality of life in patients. It initially presents with callosities and dry skin relating to diabetic neuropathy and later chronic ulcers and other malformations of the feet may develop. It is important for diabetics to check their feet regularly for any cuts or punctures because they often lose feeling in their feet.

Reference(s):

Khandelwal, Deepak, et al. “Sleep Disorders in Type 2 Diabetes.” Indian Journal of Endocrinology and Metabolism, Medknow Publications & Media Pvt Ltd, 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5628550/.

Robertson, R Paul. “Risk Factors for Type 2 Diabetes Mellitus.” St. John's University -- Academics & SchoolsLibraries,www-uptodate-com.jerome.stjohns.edu/contents/risk-factors-for-type-2-diabetes-mellitus?search=sleep%2B%2B%2Bdiabetes&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2.

Rosen J, Yosipovitch G. Skin Manifestations of Diabetes Mellitus. [Updated 2018 Jan 4]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK481900/