Transcript Adverse effects of therapy for diabetes

Cutaneous Manifestations of
Diabetes Mellitus
Dr Noreen Cowley
MD FRCP
Consultant Dermatologist
Cutaneous
No Pathonomonic Skin lesion in Diabetes
Cutaneous Manifestations of
Diabetes
30% incidence cutaneous disorders ADA
70% during course of illness
15% ulceration
Cutaneous Manifestations of
Diabetes
Hyperglycaemia
Neuropathy
Impaired host response
Microvascular angiopathies with failure of the
microcircutation to meet the metabolic requirements
of the skin
Cutaneous Manifestations of
Diabetes
• Common disorders that affect non-diabetes
• Those classically associated with diabetes / reflect
microangiopathy
• Lesions indicating poor control
• Effect of insulin resistance
• Adverse effects of therapy for diabetes
• Skin changes as a result complications of diabetes
• Other associated autoimmune disorders
Cutaneous Manifestations of
Diabetes
• Common disorders that affect non-diabetics
• Those classically associated with diabetes / reflect
microangiopathy
• Lesions indicating poor control
• Effect of insulin resistance
• Adverse effects of therapy for diabetes
• Skin changes as a result complications of diabetes
• Other associated autoimmune disorders
Skin Infection
20-50% (Type 2) poor glycaemic control
Poor micro and macro-circulation
Neuropathy
Altered immune response
Dermatoses “portal of entry”
Skin Infection
Staphylococcus folliculitis
Superficial fungal infection
Cellulitis and erysipelas
Oral and genital candida
Non pathogenic organisms
mucormycosis by phycomycetes
and anaerobic cellulitis by clostridium species
Erythrasma
Cutaneous Manifestations of
Diabetes
• Common disorders that affect non-diabetes
• Those classically associated with diabetes / reflect
microangiopathy
• Lesions indicating poor control
• Effect of insulin resistance
• Adverse effects of therapy for diabetes
• Skin changes as a result complications of diabetes
• Other associated autoimmune disorders
Necrobiosis Lipoidica
Necrobiosis Lipoidica
Necrobiosis Lipoidica
Aetiology
Microangiopathy –---collagen degradation with
release cytokines from inflammatory cells –
destruction collagenous matrix
Little evidence correlation
retinopathy/nephropathy
Necrobiosis Lipoidica
0.3-0.7%
Differential Diagnosis
Generalized Granuloma
Annulare
Diabetic Dermopathy
“Shin Spots”
Shemer et al 40%
Men – 50yrs
Diabetic Dermopathy
Severe microvascular complications
Retinopathy,neuropathy,nephropathy
Closely linked to glycosylated Hb
High risk of accelerated diabetes complications
Bullosis Diabeticorum
Bullosis Diabeticorum
Type 1 Diabetes
0.5%
Men
Longstanding Disease
Peripheral Neuropathy
Cutaneous Manifestations of
Diabetes
• Common disorders that affect non-diabetes
• Those classically associated with diabetes / reflect
microangiopathy
• Lesions indicating poor control
• Effect of insulin resistance
• Adverse effects of therapy for diabetes
• Skin changes as a result complications of diabetes
• Other associated autoimmune disorders
Eruptive Xanthomas
Scleredema of Buschke
Scleredema of Buschke
Type 2
Obese
Therapy resistant
Cardiovascular
Retinopathy
Cutaneous Manifestations of
Diabetes
• Common disorders that affect non-diabetes
• Those classically associated with diabetes / reflect
microangiopathy
• Lesions indicating poor control
• Effects of insulin resistance
• Adverse effects of therapy for diabetes
• Skin changes as a result complications of diabetes
• Other associated autoimmune disorders
Acanthosis Nigricans
8 types
Obesity – Acanthosis Nigricans
Kahn 1975
association with
insulin resistance
Acanthosis Nigricans
Mechanism?
High insulin concentrations stimulate
insulin–like growth factor receptors on
keratinocytes promoting epidermal cell proliferation
HAIR-AN Syndrome
• HyperAndrogenism
• Insulin Resistance
• Acanthosis Nigricans
HAIR-AN Syndrome
Type A I R
Mutation gene that encodes the
insulin receptor
Tall black young females
Severe acanthosis nigricans
begins infancy and early childhood
Alopecia
Cutaneous Manifestations of
Diabetes
• Common disorders that affect non-diabetes
• Those classically associated with diabetes / reflect
microangiopathy
• Lesions indicating poor control
• Effect of insulin resistance
• Adverse effects of therapy for diabetes
• Skin changes as a result complications of diabetes
• Other associated autoimmune disorders
Auto-Immune Disorders
Vitiligo
1-7% in diabetes
0.2-1% non-diabetic
Lichen Sclerosis et Atrophicus
Lichen Sclerosis et Atrophicus
Cutaneous Manifestations of
Diabetes
• Common disorders that affect non-diabetes
• Those classically associated with diabetes / reflect
microangiopathy
• Lesions indicating poor control
• Effect of insulin resistance
• Adverse effects of therapy for diabetes
• Skin changes as a result complications of diabetes
• Other associated autoimmune disorders
Cutaneous effects of Therapy
• Insulin
• Oral hypoglycaemic agents
Metformin
Psoriasiform drug eruption
Erythema Multiforme
Leucocytoclastic Vasculitis
Lipoatrophy/hypertrophy
Lipoatrophy
Thighs/arms children and
young women
Lipohypertrophy
Males
Subcutaneous deposition
fat at injection sites
Insulin –induced
stimulation of adipose
tissue growth
Cutaneous Manifestations of
Diabetes
• Common disorders that affect non-diabetes
• Those classically associated with diabetes / reflect
microangiopathy
• Lesions indicating poor control
• Effect of insulin resistance
• Adverse effects of therapy for diabetes
• Skin changes as a result complications of diabetes
• Other associated autoimmune disorders
Perforating Collagenosis
Perforating Collagenosis
Elimination of
focally
damaged
collagen
through the
epidermis
Necrolytic Migratory Erythema
Stomatitis
Weight Loss
Diabetes Mellitus
Glucagon-secreting tumour
of the pancreatic islet cells
Mechanism?
Sustained gluconeogenesis from high glucagon levels leads to
amino acid deficiency,epidermal protein deficiency and necrolysis
Thankyou
Any Questions?