PATTERN OF CUTANEOUS MANIFESTATIONS IN DIABETES MELLITUS Abhishek Goyal, Sujeet Raina, Satinder S Kaushal, Vikram Mahajan,1 and Nand

Lal Sharma1 Indian J ermatol! "#1# Jan$Mar% &&'1() *+,-1 Abstract Background: iabetes mellitus a..e/ts indi0iduals o. all a1es and so/ioe/onomi/ status! Skin is a..e/ted by the a/ute metaboli/ deran1ements as 2ell as by /hroni/ de1enerati0e /om3li/ations o. diabetes! Ai s: 4o e0aluate the 3re0alen/e o. skin mani.estations in 3atients 2ith diabetes mellitus! 4o analy5e the 3re0alen/e and 3attern o. skin disorders amon1 diabeti/ 3atients .rom this re1ion o. 6estern 7imalayas! Mat!ria"s and M!t#ods: 8ne hundred /onse/uti0e 3atients 2ith the dia1nosis o. diabetes mellitus and ha0in1 skin lesions, either attendin1 the diabeti/ /lini/ or admitted in medi/al 2ards 2ere in/luded in this study! R!su"ts: 4he /ommon skin disorders 2ere) 9erosis '--:(, diabeti/ dermo3athy '*;:(, skin ta1s '*":(, /utaneous in.e/tions '*1:(, and seborrhei/ keratosis '*#:(! Conc"usion: Skin is in0ol0ed in diabetes <uite o.ten and the mani.estations are numerous! 7i1h 3re0alen/e o. =erosis in our diabeti/ 3o3ulation is 3erha3s due to /old and dry /limati/ /onditions in the re1ion .or most o. the time in the year! $!%&ords: Diabetes mellitus, skin lesions, Western Himalayas
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Introduction iabetes mellitus a..e/ts indi0iduals o. all a1es and in all so/io$e/onomi/ se1ments o. the 3o3ulation! Global 3resen/e o. ty3e " diabeti/s in the year "### 2as 1>1 million 2hi/h is likely to be *;; million in the year "#*#!?1@ 4he International iabetes Aederation 'I A( estimates the total number o. diabeti/ subje/ts to be around -#!+ million in India and this is .urther set to raise to ;+!+ million by the year "#"&!?"@ Bstimates by 678 su11est that the number o. diabeti/ subje/ts 2ould in/rease to C# million by the year "#*# in India!?1@ Skin lesions are .re<uently obser0ed in diabeti/ 3atients and about *#: o. diabeti/s ha0e /utaneous disorders!?*@ 4he skin is a..e/ted by the a/ute metaboli/ deran1ements and the /hroni/ de1enerati0e /om3li/ations o. diabetes! Althou1h the me/hanism .or many diabetes$ asso/iated skin /onditions remains unkno2n, the 3atho1enesis o. others is linked to abnormal /arbohydrate metabolism, other altered metaboli/ 3ath2ays, atheros/lerosis, mi/roan1io3athy, neuron de1eneration, and im3aired host me/hanisms!?-@ 8nly a .e2 e3idemiolo1i/ studies ha0e been done on the 3re0alen/e o. skin disorders in 3atients 2ith diabetes mellitus!?*,&@ 4here are no e3idemiolo1i/ data related to skin disorders in diabeti/s re3orted .rom the Northern state o. 7ima/hal Dradesh, India! 4his study 2as desi1ned to analy5e the 3re0alen/e and 3attern o. skin disorders amon1 diabeti/ 3atients .rom this re1ion o. 6estern 7imalayas!

Mat!ria"s and M!t#ods 4he study 2as /ondu/ted in the e3artments o. Medi/ine and ermatolo1y o. IGME,

Shimla! 8ne hundred /onse/uti0e 3atients 2ith the dia1nosis o. diabetes mellitus and ha0in1 skin lesions, either attendin1 the diabeti/ /lini/ or admitted in medi/al 2ards /onstituted the study 3o3ulation! Elini/al details re1ardin1 a1e, se=, duration o. diabetes mellitus, and treatment modalities 2ere noted! All the 3atients under2ent a detailed dermatolo1i/al e=amination! Rele0ant mi/robiolo1i/al and histo3atholo1i/al in0esti1ations to /on.irm the dia1nosis 2ere /arried out!

R!su"ts 4he study /om3rised o. 1## /onse/uti0e 3atients o. diabetes mellitus 2ith skin lesions! 4here 2ere &- males and -; .emales 'M)A F 1!>)1(! 4he youn1est 3atient 2as "C years and oldest 2as C# years 2ith a mean a1e o. &>!-- G 1#!*> years! 4he duration o. diabetes 2as H1# years in ;# 3atients! 4hirty .our 3atients had 11$"# years o. diabetes, and si= had I"# years o. diabetes! 4en 3atients 2ere ne2ly dia1nosed as diabeti/s! Various ty3es o. skin lesions and duration o. diabetes mellitus obser0ed are 3resented in 4able 1! Various ty3es o. skin in.e/tions obser0ed are sho2n in 4able "! Majority o. 3atients 'C#:( had /ombination o. more than one ty3e o. skin lesions! 42enty 3atients had t2o ty3es o. skin lesions, 1" had three ty3es, si=teen had .our ty3es, and another 1; had .i0e ty3es! Si= ty3es o. skin lesions 2ere obser0ed in another 1- 3atients and only t2o 3atients 3resented 2ith a ma=imum o. se0en! 42enty 3atients had only a sin1le ty3e o. skin lesion!

Discussion Eutaneous si1ns o. diabetes mellitus are e=tremely 0aluable to the /lini/ian! 4hey 1enerally a33ear a.ter the 3rimary disease has de0elo3ed but may si1nal or a33ear /oin/identally 2ith its onset, or e0en 3re/ede diabetes by many years! Eutaneous mani.estations o. diabetes are /lassi.ied into .our /ate1ories) Skin lesions 2ith stron1$to$2eak asso/iation 2ith diabetes 'ne/robiosis li3iodi/a, diabeti/ dermo3athy, diabeti/ bullae, yello2 skin, eru3ti0e =anthomas, 3er.oratin1 disorders, a/anthosis ni1ri/ans, oral leu/o3lakia, li/hen 3lanus(, in.e/tions 'ba/terial, .un1al(, /utaneous mani.estations o. diabeti/ /om3li/ations 'mi/roan1io3athy, ma/roan1io3athy, neuro3athy(, and skin rea/tions to diabeti/ treatment 'sul3honylureas or insulin(!?*@ Most do/umented studies ha0e sho2n the in/iden/e o. /utaneous disorders asso/iated 2ith diabetes to be bet2een *# and >1:!?*,;@ In our study, the most /ommon si= skin disorders 2ere) 9erosis '--:(, diabeti/ dermo3athy '*;:(, skin ta1s '*":(, /utaneous in.e/tions '*1:(, and 3ruritis and seborrhei/ keratosis J*#: ea/h, res3e/ti0ely! 9erosis a//ounted .or the most /ommon skin mani.estation in our study and --: 3atients had =erosis althou1h 0arious studies on /utaneous lesions in diabeti/ 3atients do not /omment on the 3re0alen/e o. =erosis! 4he reason .or hi1h 3re0alen/e o.
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=erosis in our diabeti/ 3o3ulation is 3erha3s due to /old and dry /limati/ /onditions in the re1ion .or most o. the time in the year! iabeti/ dermo3athy, in the .orm o. small, atro3hi/, iabeti/ bro2n$s/ar$like ma/ules on both /hins 2ere seen in *;: o. the 3atients!

dermo3athy may de0elo3 .rom the .a/tors that lead to the de0elo3ment o. 0as/ular /om3li/ations o. diabetes and it may ser0e as a /lini/al si1n o. an in/reased likelihood o. 0as/ular /om3li/ations in diabeti/ 3atients! Skin ta1s 2ere seen in *": o. 3atients! Skin ta1s may ser0e as a marker .or diabetes mellitus as 2as /on/luded by 4ha33a et al!?>@ Eutaneous in.e/tions 2ere seen in *1: o. 3atients! Aun1al in.e/tions 2ere seen in 1;: o. the 3atients '+: had /andidal and >: had dermato3hytosis(! Ka/terial in.e/tions 2ere seen in 1&: o. the 3atients! It is 2idely belie0ed that diabeti/ 3atients ha0e an in/reased risk .or in.e/tious diseases, althou1h there is little do/umented e0iden/e to su33ort it! 4his risk seems to be hi1her in 3oorly /ontrolled 3atients, but it is o.ten di..i/ult to understand 2hether 3oor metaboli/ /ontrol is the /ause or the /onse<uen/e o. the /on/urrent in.e/tions!?-@ None o. the 3atients had 0iral in.e/tions, 2et 1an1rene, s/leroderma diabeti/orum, tro3hi/ ul/er, 1ranuloma annulare, ne/robiosis li3iodi/a, li/hen 3lanus, rea/ti0e 3er.oratin1 /olla1enosis, or dru1 rea/tions to oral hy3o1ly/emi/s in this study, althou1h these are usually asso/iated 2ith diabetes mellitus! Arom the .ore1oin1 a//ount, 2e /on/lude that the skin is in0ol0ed in diabetes <uite o.ten! 4he mani.estations are numerous and 0aried and many a times they /an ser0e as dia1nosti/ marker .or underlyin1 diabetes! 6hene0er 3atients 3resent 2ith multi3le skin mani.estations, their diabeti/ status should be /he/ked! 4he re/o1nition o. these skin .indin1s is the key to treatment and 3re0ention!

Footnot!s Sourc! o' Su((ort: Nil Con'"ict o' Int!r!st: Nil!

R!'!r!nc!s 1! 6ild S, Ro1li/ G, Green A, Si/ree R, Kin1 7! Global 3re0alen/e o. diabetes, estimates .or the year "### and 3roje/tion .or "#*#! iabetes Eare! "##-%">)1#->,&*! ?DubMed@ "! Si/ree R, Sha2 J, Limmet D! Aederation% "##;! 33! 1&,1#*! *! Romano G, Moretti G, i Kenedetto A, Gio.re E, i Eesare B, Russo G, et al! Skin lesions in diabetes mellitus) Dre0alen/e and /lini/al /orrelations! 1++C%*+)1#1,;! ?DubMed@ -! Khat MJ, Gu3ta V, Kudyar RD! Eutaneous mani.estations o. diabetes mellitus! Int J e0 Etries! "##;%";)1&",&! &! Sasma5 S, Kuyukbese MA, Eetinkaya A, Eelik M, Ari/an 8! 4he 3re0alen/e o. skin disorders in ty3e$" diabeti/ 3atients! Int J ermatol! "##&%*)1! ;! Mahajan S, Koranne RV, Sharma SK! Eutaneous mani.estation o. diabetes melitus! Indian J ermatol Venereol Le3rol! "##*%;+)1#&,C! ?DubMed@ >! 4ha33a M! Skin ta1s as markers o. diabetes mellitus) An e3idemiolo1i/al study in India! J ermatol! 1++&%"")>"+,*1! ?DubMed@ iab iabetes Res Elin Dra/t! iabetes and im3aired 1lu/ose toleran/e! In) Gan , editor! iabetes iabetes atlas! International diabetes .ederation! *rd ed! Kel1ium) International

FI)URES AND TABLES

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4able 1 4y3e o. skin lesions obser0ed in diabetes mellitus T%(!s o' skin "!sions 9erosis iabeti/ dermo3athy Skin ta1s In.e/tions Seborrhei/ keratosis Nail /han1es 9anthalasma I/hthyosis A/anthosis ni1ri/ans Vitili1o S/leroderma$like skin iabeti/ rubeosis S/abies Li3odystro3hy Ma/ular amyloidosis Nodular 3ruri1o iabeti/ bullae Alo3e/ia Dlantar 3soriasis An1iomatosis Rosa/ea Asteatoti/ e/5ema Keloid Ne0i Dhotodermatitis Nu b!r o' (ati!nts -*; *" *1 *# "# 1# 1# C C ; " " " " " " " " "

4able " 4y3e o. skin in.e/tion in diabetes mellitus

T%(! o' skin in'!ction Ka/terial in.e/tion Im3eti1o /onta1iosa Koils Brythrasma Aolli/ulitis Aun1al in.e/tion Eandidal ermato3hytosis

Nu b!r o' (ati!nts ; " * + >

Arti/les .rom Indian Journal o. ermatolo1y are 3ro0ided here /ourtesy o. M!dkno& Pub"ications