Diabetes mellitus affects about 30 million Americans, or 9.4% of the population.1

Whether it is type 1 or type 2, diabetes can affect every part of the body, including the skin. Skin complications are often the first sign of diabetes.2 Caught early, most skin conditions can be prevented or easily treated. Several kinds of bacterial infections can occur in people with diabetes (see table 13,4).

Table

In the past, bacterial infections could be life-threatening for people with diabetes.3 With better blood sugar control methods and effective antibiotics, outcomes are better.

SKIN CONDITIONS UNIQUE TO DIABETES
Five skin conditions tend to occur in people with diabetes, and their pathogeneses is poorly understood. Diabetic dermopathy is the most common dermatologic manifestation of diabetes. About half of patients with diabetes develop diabetic dermopathy, and it is more prevalent in adults older than 50 years and men.5,6 Diabetic dermopathy presents with round red papules that progressively evolve over 1 to 2 weeks into brown macules. The area around the ankles, forearms, shins, and thighs are most commonly affected. Nephropathy, neuropathy, and retinopathy are present in this condition. Clinicians typically avoid treating diabetic dermopathy, because of a lack of available drugs to treat it and its self-resolving nature. No evidence indicates that improving glycemic control alters diabetic dermopathy.5,6

Acanthosis nigricans affects people of all ages and is more prevalent in those with darker-skin color with type 2 diabetes.7,8 It presents with multiple demarcated plaques with grey to dark-brown hyperpigmentation and thickened texture. Symmetrically distributed, it usually appears on the armpits, back of the neck, elbows, or groin. Hyperkeratosis causes skin pigmentation changes that can present before diabetes is diagnosed. Acanthosis nigricans is best managed with lifestyle changes, such as dietary modifications, increased physical activity, and weight reduction. Metformin with other pharmacologic adjuvants that improve glycemic control are also beneficial.2

LESS COMMON SKIN CONDITIONS
Eruptive xanthomas are associated with serum triglycerides above 2000mg/dL.9 It begins with clusters of glossy pink or yellow papules that can be itchy or tender, ranging in diameter from 1 mm to 4 mm. Histology shows a mixed inflammatory infiltrate of the dermis, which includes triglyceride-containing macrophages. Improving glycemic control and reducing serum triglyceride levels can resolve this condition. In addition to patients’ insulin regimens, fibrates and omega 3 fatty acids can help.2

Necrobiosis lipoidica presents with a single or group of firm well-demarcated rounded erythematous papules. They expand and aggregate into plaques with a firm yellow brown center and red-brown borders. Patients may report numbness, painful ulceration, or pruritis. Corticosteroids can be used intralesionally, orally, or topically. Other medications that have been effective include anti-tumor necrosis factor inhibitors, calcineurin inhibitors, and dipyridamoles.2

Finally, bullosis diabeticorum is an eruptive blistering condition, with a 0.5% prevalence among patients with diabetes that is more common in males than in females.10 Firm, non-erythematous, sterile blisters filled with fluid form abruptly. The bullae increase in size from 0.5 cm to 5 cm, becoming more flaccid. It presents bilaterally involving the palms and soles.11 The bullae generally heal within 2 to 6 weeks but commonly reoccur. Unless secondary infection develops, bullae resolve without treatment. Topical antibiotics are unnecessary, unless infection occurs.2

Pharmacists are critical to effective counseling (see table 23).



CONCLUSION
Many of these counseling points can be addressed when patients pick up their medications. This can prevent future complications and reduce redundant appointments with their primary care.


REFERENCES
  1. Diabetes mellitus type 2 in adults. DynaMed website. Updated November 30, 2018. Accessed March 27, 2020. https://www.dynamed.com/condition/diabetes-mellitus- type-2-in-adults
  2. Rosen J, Yosipovitch G. Skin Manifestations of Diabetes Mellitus. In: Feingold KR, Anawalt B, Boyce A, et al., editors. 2000. Updated [January 4, 2018] EndotextMDT https://www.ncbi.nlm.nih.gov/books/NBK481900/
  3. American Diabetes Association. Skin complications. Accessed March 27, 2020. https://www.diabetes.org/diabetes/complications/skin-complications
  4. Cleveland Clinic. Care for diabetes skin problems. Updated February 23, 2015. Accessed March 27, 2020. https://my.clevelandclinic.org/health/articles/9491-diabe- tes-skin-care
  5. Stuart CA, Driscoll MS, Lundquist KF, Gilkison CR, Shaheb S, Smith MM. Acanthosis nigricans. J Basic Clin Physiol Pharmacol. 1998;9(2-4):407-418. doi: 10.1515/jbcpp.1998.9.2-4.407
  6. Bustan RS, Wasim D, Yderstræde KB, Bygum A. Specific skin signs as a cutaneous marker of diabetes mellitus and the prediabetic state - a systematic review. Dan Med J. 2017;64(1):A5316.
  7. Morgan AJ, Schwartz RA. Diabetic dermopathy: A subtle sign with grave implica- tions. J Am Acad Dermatol. 2008;58(3):447-451.
  8. Stuart CA, Gilkison CR, Smith MM, Bosma AM, Keenan BS, Nagamani M. Acanthosis nigricans as a risk factor for non-insulin dependent diabetes mellitus. Clin Pediatr (Phila). 1998;37(2):73-79.
  9. Sugandhan S, Khandpur S, Sharma VK. Familial chylomicronemia syndrome. Pediatr Dermatol. 2007;24(3):323-325.
  10. Romano G, Moretti G, Di Benedetto A, et al. Skin lesions in diabetes mellitus: prevalence and clinical correlations. Diabetes Res Clin Pract. 1998;39(2):101-106.
  11. Larsen K, Jensen T, Karlsmark T, Holstein PE. Incidence of bullosis diabetico- rum--a controversial cause of chronic foot ulceration. Int Wound J. 2008;5(4):591-596. doi: 10.1111/j.1742-481X.2008.00476.x