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A cross sectional study of cutaneous manifestations in 300 patients of diabetes mellitus

Diabetes Mellitus (DM) is a worldwide problem and one of the most common endocrine disorder affecting 8.3% of the population. Its prevalence is increasing due to increase sedentary lifestyle in the general population. Abnormalities of insulin and elevated blood glucose levels lead to metabolic, vascular, neurological and immunological abnormalities. The skin is affected by both the acute metabolic derangements and the chronic degenerative complications of diabetes. Although the mechanism of many diabetes associated skin conditions remains unknown. Diabetes has a profound effect on both cells mediated and humoral immunity and also on the ABSTRACT


INTRODUCTION
Diabetes Mellitus (DM) is a worldwide problem and one of the most common endocrine disorder affecting 8.3% of the population. 1 Its prevalence is increasing due to increase sedentary lifestyle in the general population. Abnormalities of insulin and elevated blood glucose levels lead to metabolic, vascular, neurological and immunological abnormalities. The skin is affected by both the acute metabolic derangements and the chronic degenerative complications of diabetes. Although the mechanism of many diabetes associated skin conditions remains unknown. Diabetes has a profound effect on both cells mediated and humoral immunity and also on the function of polymorphonuclear cells that predisposes these individuals to a variety of infections. Microcirculatory alteration, lipid profile alteration and glycosylation of proteins with production of advanced glycosylated end product and their deposition in the basement membrane results in cutaneous manifestations in diabetic patients. 2 Endothelial functions also affected in diabetes mellitus. 3 Abnormal carbohydrate metabolism, atherosclerosis, microangiopathy, neuropathy and impaired host immune mechanisms all play a role in the pathogenesis of cutaneous complications. 8 Skin manifestations can be the first presenting sign of diabetes but more often appear in known diabetic patients during the course of the disease as observed in 43-66% of diabetic patients. 4 The aims and objectives were to study the clinical pattern of cutaneous manifestations in patients of diabetes mellitus, the relation of these cutaneous manifestations with demographic data like age, sex and duration of diabetes, and to compare the cutaneous manifestations in controlled and uncontrolled diabetes.

METHODS
Study includes a total number of 300 patients of type 1 and type 2 diabetes mellitus with cutaneous manifestations attending dermatology OPD were included in study conducted in duration for 1year.
The patients with all confirmed (old and new) cases of diabetes mellitus with cutaneous manifestations irrespective of age, sex, duration of illness and associated diseases, willing to participate in the study were included. The patients not willing to participate in the study were excluded.
Ethical clearance was obtained. In the selected patients, a detailed history with reference to demographic details, family history of similar complaints and of DM, duration of DM treatment details, duration of various symptoms and evolution of lesions was taken. The patients will be clinically examined in good light for various cutaneous manifestations of DM such as skin lesions, nail changes, mucous membrane involvement.
Following investigations were done in all the patients: • Routine haematological and urine investigations such as Hb%, TC, DC, ESR, RBS, urine routine and microscopy will be done in all patients, • Fasting blood sugar, random blood sugar, • Glycosylated (glycated) haemoglobin (HbA1c), • Investigations will be done to diagnose cutaneous manifestations associated with DM.
• Potassium hydroxide mount, • Gram staining, • Bacterial and fungal culture, • Skin biopsy, The comparison of cutaneous manifestations in controlled and uncontrolled diabetes mellitus was done using Chisquare test.

RESULTS
The present study was undertaken to know the spectrum of cutaneous manifestations in diabetes mellitus. Majority belonged to the 4 th decade (33%) and 3 rd decade (27.7%) respectively (Table 1).  Hypertension was the most commonly associated systemic illness (37.6%) followed by ischemic heart disease (15.33%) and hypothyroidism (5.3%). Among the various cutaneous manifestations observed, cutaneous infections (63%) were the most commonly observed (Table 3). Among the cutaneous infections, fungal infections (35.3%) were most frequently observed, followed by bacterial infections (20%) and viral infections (7.66%). Dermatophytosis was the most commonly observed fungal infections (74 cases) followed by candida infections (16 cases).  Cutaneous infections, dermatoses associated with microangiopathy, dermatoses associated more commonly, metabolic disorder and non-specific manifestations were more common in the uncontrolled diabetic patients (Table 5). In the present study, among the various dermatological manifestations, infections were the most common dermatoses (63%), followed by dermatoses having a more common association with diabetes (47.66%), followed by non-specific cutaneous manifestations (34.33%), followed by due to microangiopathy (6.66%), neuropathic and ischemic diabetic skin disease (7.33%), metabolic diseases (2.33%) and cutaneous reactions to therapy for diabetes (0.67%) Similar findings were reported by other studies. [4][5][6][7] Infections were the most common dermatoses (63%), of which fungal infections were most prevalent (35.3%), followed by bacterial infections (20%) and viral infections (7.66%). This was in accordance with other studies where fungal infections were more common, as observed by Mahajan  Acanthosis nigricans and acrochordons are manifestations of insulin resistance, which may be present before the expression of DM. Increased levels of insulin act on insulin like growth factor (IGF) receptors, resulting in development of acanthosis nigricans. In a study by Nigam PK et al, dermatoses associated with an increased incidence of DM, like vitiligo (4), lichen planus (2), acquired perforating dermatoses (3) were detected. 5 Of the 103 patients who presented with non-specific manifestations, majority of them had eczema 30 (10%), 15 patients (5%) had seborrheic keratoses, 7 patients (2.33%) had urticaria, 6 patients each (2%) had pemphigus and seborrheic dematitis, 5 patients (1.66%) had lichen simplex chronicus hypertrophicus, 4 patients each (1.33%) had DPN, contact dermatitis, scabies and polymorphous light eruption, 3 patients each (1%) had prurigo nodularis and androgenic alopecia, 2 patients each (66%) had drug reactions, erythema multiforme, keloid and parapsoriasis and one case each (0.33%) of sebaceous cyst, dermatitis herpetiformis, senile comedones and melasma. The occurrence of nonspecific cutaneous disorders also has pathogenetic, prognostic, and therapeutic importance in diabetic patients. These disorders could also increase the likelihood of exposure to contact allergens resulting in eczemas. 9 Among the 300 diabetic patients with cutaneous manifestations, 154 patients had HbA1c <8% (good to moderate control) while 132 patients had a poor control of diabetes (HbA1c >8%) the present study, when a comparison of pattern of cutaneous manifestations in the controlled and uncontrolled groups was done, it was found that the cutaneous infections, dermatoses associated with microangiopathy, neuropathic and ischemic diabetic skin disease and dermatoses more commonly associated were more common in the uncontrolled group, which was statistically significant (P<0.05). The increased frequency of non-specific manifestations in the controlled group was meaningfully significant.

CONCLUSION
The present study was undertaken to know the spectrum of cutaneous manifestations in diabetes mellitus. Infections were the most common cutaneous manifestations in diabetics, followed by dermatoses most commonly associated with diabetes.
Cutaneous manifestations are more common in patients who have overall poor glycemic control which in turn is reflected by high HbA1c value. Cutaneous manifestations can heighten the suspicion of a physician regarding the diagnosis of diabetes. This further helps to prevent systemic derangements by early institution of appropriate treatment.
Proper skin care and long-term control of blood glucose levels may reduce the risk of some of the skin lesions in diabetic subjects. Thus, dermatologists can play an important role in reducing dermatologic morbidity, improvement of quality of life and management strategy of diabetic patients.