PATTERN OF CUTANEOUS MANIFESTATIONS OF DIABETES MELLITUS

Background: Diabetes mellitus affects individuals of all ages and socioeconomic status. Skin is affected by the acute metabolic derangements as well as by chronic degenerative complications of diabetes. Aims: To evaluate the prevalence of skin manifestations in patients with diabetes mellitus. To analyze the prevalence and pattern of skin disorders among diabetic patients from this region of Western Himalayas. Materials and Methods: One hundred consecutive patients with the diagnosis of diabetes mellitus and having skin lesions, either attending the diabetic clinic or admitted in medical wards were included in this study. Results: The common skin disorders were: Xerosis (44%), diabetic dermopathy (36%), skin tags (32%), cutaneous infections (31%), and seborrheic keratosis (30%). Conclusion: Skin is involved in diabetes quite often and the manifestations are numerous. High prevalence of xerosis in our diabetic population is perhaps due to cold and dry climatic conditions in the region for most of the time in the year.

general, type two DM patients tend to develop more frequent cutaneous infections, whereas type one DM patients develop more autoimmune type of cutaneous lesions . [4][5] Hyperglycemia leads to nonenzymatic glycosylation (NEG) of various structural and regulatory proteins including collagen. NEG leads to formation of advanced glycosylation end products (AEG), which contribute to pathogenesis of disorders such as diabetic thick skin and limited joint mobility (LJM) . The etiopathogenesis of systemic and 6 cutaneous infections which are a significant cause of morbidity and mortality in DM is linked to derangements in immuno regulatory mechanism like diminish chemotaxis, phagocytosis and reduced cell mediated immunity . 7 Metabolic abnormalities like hyperinsulinemia seen in early type 2 DM, by virtue of its action on insulin like growth factors -I (IGF-1) receptor appears to mediate abnormal epidermal proliferation and phenotype of acanthosis nigricans . In 8 insulin deficient diabetic patients abnormal Lipoprotein lipase (LPL) activity resulting in defective lipid processing and can lead to massive hypertriglyceridemia manifesting in skin as eruptive xanthomas. Macro and microangiopathy contribute significantly to the cutaneous complications of diabetes. In addition, a loss of cutaneous sensory innervations occurs with diabetes. All the above factors in combination and loss of neuroinflammatory cell signaling plays a casual role in non-healing, lower extremity ulcers . Cutaneous lesions in 9 diabetes may be classified into four major groups:

AIMS AND OBJECTIVES:
The aim of this study is to study dermatological manifestations of diabetes mellitus.

MATERIAL AND METHODS:
This study was carried out on 200 patients of diabetes mellitus with cutaneous manifestations attending out-patient department of Dermatology at Jawahar Lal Nehru, Medical College, Ajmer. Inclusion criteria for study were patient with raised fasting or postprandial blood sugar level as per diagnostic criteria for diabetes mellitus adopted by American Diabetes Association 2019 and those require treatment for diabetes mellitus both type 1 and type 2 . Those 10 with gestational diabetes were excluded from the study. A detailed history including age, sex, occupation socioeconomic status, clinical sign and symptoms, their duration, history of evolution and progression of lesion and its treatment, if any, were recorded. A thorough dermatological, general physical and systemic examination were done. All cutaneous and mucous lesions were recorded. Relevant laboratory investigation including complete blood count, blood sugar both f asting and postprandial, ur ine examination, liver and kidney function test, HbA1c, lipid profile, fundus examination by an ophthalmologist, KOH examination, gram staining of pus in selected cases were done.
Assessment of diabetic neuropathy was done on basis of criteria detailed by foster. Relevant microbiological and histopathological examination were carried out in selected cases to confirm clinical diagnosis.

RESULTS:
During the study 200 patients of diabetes mellitus with cutaneous manifestations were observed and following information were recorded. The mean age of patient in this study is 52.48 years (ranges from 3.5-80 years     (14), candidal balanoposthitis 5.5% (11) and least common was candidal paronychia in 1.5% (3) patients. were present in 3% (6) cases. Specific dermatosis have shown association with diabetes mellitus in many studies like diabetic bullae, necrobiosis lipoidica, granuloma annulare. The above specific dermatosis were also present in our study respectively in 0.51% (1) case, 1.5% (3) 2% (4) cases. Similar results have been shown by Tariq Mahmood et al and 18 Braverman IM . These specific dermatosis were present in 19 our study at frequency similar to other studies like Pandey et al . Amongst 200 patients few cases due to complications of 20 therapy were also observed. Lipohypertrophy at injection site due to insulin was present in one case 0.5% (1) case, erythema multiforme like skin rash due to oral hypoglycemic drugs was seen in 0.5% (1) case. Few cases of photodermatitis like rash were also observed.

CONCLUSION:
Thus, a variety of cutaneous manifestations in diabetes mellitus have been observed in our study which helps to diagnose diabetes merely by careful inspection of skin. Skin manifestation of diabetes mellitus generally appear after systemic disease has developed but in few cases may predate or even appear concurrently with it.