Many medical diseases are frequently accompanied by little known skin manifestations, and never is this more likely then when considering diabetes. After all, the skin is the largest organ of the body. So, it's not surprising that diabetes, a disease that affects so many organ systems, can also do a number on the skin. Diabetic patients need to familiarize themselves with daily skin care necessities to help maintain overall health of the skin. This can help keep skin happy, healthy and reduce risks that can arise when small problems are left unchecked.

Diabetes is a state of uncontrolled blood sugar due either to a lack of insulin or resistance to this hormone. Insulin is essential for converting sugar and starches into energy. Over seventeen million people in the Unites States are thought to suffer from diabetes which can be broken down into three categories:

Type I: Is due to a failure of the body (pancreas) to produce insulin. Type I diabetes is often called juvenile diabetes, as this is the form most commonly seen beginning in childhood. An estimated 5-10% of the population have type I diabetes.

Type II: Is due to insulin resistance. The body is unable to properly utilize insulin. Some think that insulin resistance is tied to our diets, especially those high in sugars and carbohydrates. Insulin resistance may also be combined to some degree with relative insulin deficiency. Type II diabetes is the most common form of this disease and accounts for 90-95% of cases.

Gestational Diabetes: Affects approximately 4% of all pregnancies or 135,000 cases in the U.S. annually. Gestational diabetes is a risk factor for developing Type II diabetes later in life.

High levels of sugar cause the kidneys to draw vital water from the bloodstream, increasing urination. As a result, the skin becomes extremely dehydrated, inflamed and cracked. Broken skin also creates a portal of entry to infection-causing germs. Dehydration is further complicated, as poor nerve function (diabetic neuropathy) diminishes the production of sweat. While excessive sweating is undesirable, a normal level of sweating helps keep skin moist.

Uncontrolled blood sugars also increase susceptibility to infection, including bacteria, fungus and yeast. Diabetic patients are far more prone to developing conditions ranging from cellulitus (bacterial skin infections), athlete's foot (a fungal infection) and nail fungus to perleche (a yeast infection affecting the corners of the mouth) and intertrigo (a yeast infection arising within skin folds).

High blood sugar and reduced blood flow affects the cutaneous nerves and sensation becomes altered. Diabetic patients become unable to sense trauma, and injuries can go unnoticed. Daily monitoring of the skin, particularly on the hands and feet, helps quickly pick up on small nicks and sores before they get out of control.

Recommended Routine Daily Skin Care For Diabetics

• Cleanse daily with a gentle cleansing agent like Vanicream Cleansing Bar.
• Apply a hydrating moisturizer with barrier action such as Vanicream Moisturizing Skin Cream, 4 oz or TheraSeal Hand Protection twice daily, particularly to lower legs, soles of feet and hands.
• Apply an antifungal cream to feet, toes nails and toe webs once daily preventatively such as DERMAdoctor Feet Accompli Ultimate Antifungal Pedicure Cream.
• Wear supportive compression socks or hosiery to reduce fluid pooling in the lower legs and feet such as Jobst.
• Cut toe nails straight across and not too short to help avoid ingrown toe nails.
• Avoid tight, binding shoes in favor of wearing loose fitting shoes.
• Inspect feet and hands daily for minor cuts and scrapes. Begin wound care immediately with antibiotic cream such as Polysporin First Aid Antibiotic Ointment twice daily to help prevent bacterial infection.
• Don't over bathe. Excessive bathing leads to dryness. Once a day bath or shower is adequate for routine grooming.
• Apply a moisturizer immediately after toweling dry.
• Reduce water temperature for bathing to warm rather than steamy hot.
• Treat skin gently. Try not to scrub, rub or scratch skin as much as possible.
• Use a humidifier to help keep the air moisture content high particularly during cold, dry weather.

Disorders More Unique To Diabetes

While not all of these disorders affect only those with diabetes, they do tend to be far more prevalent in these patients.

Necrobiosis Lipoidica Diabeticorum

Necrobiosis lipoidica diabeticorum (NLD) is considered one of the quintessential eruptions associated with diabetes, however only 0.3-0.7% of diabetics ever develop this disorder. NLD consists of slow growing yellowish shiny, waxy-looking plaques, later developing depressed (atrophic) centers. Primarily affecting the shins, NLD tends to affect three times as many women as men. The average age of onset is 30, although this condition has been reported to affect those ranging from early childhood to seniors. NLD tends to be symmetrical, affecting both lower legs. When it develops elsewhere, it is less likely to be associated with diabetes.

Necrobiosis lipoidica diabeticorum (NLD) is a disorder of collagen degeneration with accompanying granulomatous formation and thickening of blood vessel walls within the dermis with co-existing thinning of the epidermis. While the precise cause of NLD is unknown, diabetic microangiopathy (narrowing of the blood vessels due to a deposition of glycoprotein) is highly suspect. Microscopic vascular changes that affect the eyes and kidneys in diabetics resemble those seen in NLD. Other theories implicate collagen abnormalities, response to trauma or metabolic causes.

You don't have to have diabetes to develop NLD, but odds are that one will develop it or have it already. 60% of patients affected by NLD tend to carry a diagnosis of diabetes prior to the development of the rash. Another 15% develop the rash prior to the onset of their diabetes. Necrobiosis lipoidica diabeticorum has no correlation to diabetes, the level of DM severity or control.

NLD is typically unsightly but not routinely associated with discomfort. However, with progression, the areas may become numb (up to 75% of patients) due to dermal nerve damage. In 25% of cases they can become painful.

NLD is difficult if not impossible to control. There are random reports of oral ticlopidine, nicotinic acid, clofazimine, dipyridamole and aspirin, as well as intralesional heparin injections showing some benefit. For those cases of NLD that progress into significant atrophy, topical tretinoin has had some reported benefit.

The use of topical steroids, intralesional steroid injections and/or steroid tapes can reduce associated inflammation early on, as well as reduce the level of the raised leading border. However, steroids can contribute or hasten atrophy and should be discontinued if signs of skin atrophy are seen.

As localized trauma can cause NDL to ulcerate in up to 1/3 of cases, protection of the legs with elastic support stockings (such as Jobst) can be helpful. Bovine collagen dressings may be beneficial in healing open wounds. Infection prevention is critical in preventing cellulitus (a bacterial infection of the skin often requiring antibiotic treatment) from forming. Ulcerations may heal with scarring or discoloration.

Diabetic Dermopathy

Approximately 40% of diabetic patients over the age of 50 have diabetic dermopathy. These rounded, depressed (atrophic), darkened spots on the shins are commonly referred to as shin spots. Diabetic dermopathy is considered the most common skin change associated with diabetes. Swelling within the dermis and thickening of the cutaneous blood vessels is associated with red blood cells finding their way out of the vessels and into the dermis. Once these blood cells have disintegrated, they can leave behind their hemosiderin, which is responsible for the brown spots. The findings of diabetic dermopathy can also be intertwined with those of stasis dermatitis. Eczematous, dry skin patches perhaps combined with inflammation, broken skin areas and even swelling of the lower legs may be seen. Some of this can be due to underlying atherosclerosis due to the DM resulting in poor skin circulation. Some may also be a result of skin dehydration associated with diabetes.

Daily moisturizer use helps hydrate parched and broken skin. The use of topical steroid creams (Cortaid Maximum Strength Cream is OTC, otherwise a prescription strength can be given) may be used on inflamed areas.

Pressure stockings, socks and hosiery (Jobst) help prevent fluid collection within the skin. Circulatory issues may need to be addressed with ultrasound evaluation. Rarely, angiography with accompanying angioplasty of the leg veins may be required. This tends to be reserved for those developing recurrent and painful leg and foot ulcerations. Oral medications to help maintain blood flow such as daily baby aspirin or Trental are common physician recommended treatments.

Any sign of infection is addressed with topical wound care with Polysporin First Aid Antibiotic Ointment and hydrogen peroxide and potentially oral antibiotics.

Prophylactic use of topical antifungal cream to feet and toes (DERMAdoctor Feet Accompli Ultimate Antifungal Pedicure Cream) help to prevent fungus from setting up shop in microscopically broken skin. It has been shown that this step greatly reduces the risk of diabetic patients developing a future case of cellulitus.

Diabetic Ulcers

Nothing is more feared than the diabetic ulcer. An estimated 2 to 3 percent of diabetics form painful often debilitating ulcerations each year. At some point an overwhelming 15 percent of all diabetics will find themselves confronted with chronic ulceration. Typically developing on the lower legs or feet these sores form from 2 main causes: poor circulation or trauma (due to diabetic neuropathy) combined with faulty wound healing. And least you think that these are merely an annoyance, the majority of diabetics who face lower leg amputation first deal with leg or foot ulceration (70-90%).

So understanding options in ulceration care is extremely important. It can help hasten healing, reduce discomfort and in many cases help prevent formation as well as improve prognosis.

Diabetes affects many steps in wound healing. Decreased collagen synthesis reduces both the ability of the wound to heal in and scar strength. High blood sugar also affects cellular ability to function. There is also a decrease or absence of growth factors in diabetic ulcerations, which are essential for maximum wound healing. Developing wound care technology is aimed at addressing these concerns.

New onset little leg ulcerations tend to be so common that initial treatment is aimed at localized wound care, infection control and maximizing blood flow to the skin. The use of antibiotic ointments and moist dressings is the first step. Improving fibroblast activity and collagen formation can help strengthen healing skin. GHK copper peptides were intially developed to help in wound care. Complex Cu3 Intensive Tissue Repair Cream is used in wound care management for this purpose in diabetic ulcerations as well as other forms of wounds.

It's often a mistake in this setting to go the wet to dry approach. Lifting off the dry dressing can cause more harm than good. There's a bevy of hydrophilic wound care dressings on the market. If your physician seems unfamiliar with diabetic wound care, there is often a wound care nurse or department affiliated with the local hospital.

Here again, it's important to prevent pooling of blood in the lower legs. Compression with medical hosiery helps reduce vascular insufficiency. In essence this means swelling of tissue surrounding tiny already compromised blood vessels is minimized which helps prevent them from closing in on the blood vessels from the outside, essentially improving overall levels of oxygen reaching the skin. Toxin build-up within the skin is also reduced. Jobst SensiFoot Unisex Athletic Support Socks, Mild Compression 8-15 mmHg, Jobst Women's Casual Knee High Socks 8-15 mmHg and Jobst forMen Knee High Socks Mild Compression 8-15 mmHg are all excellent daily wear options.

The use of oral medications like Trental (pentoxyfilline) can help improve blood flow through narrowed blood vessels within the skin and help restore some oxygen content, vital for preventing as well as healing ulcerations.

Narrowing of major blood vessels in the legs may need to be addressed as well, initially with ultrasonography. More invasive yet effective angiography accompanied with angioplasty helps look at blood vessels and pop them open.

Currently the only growth factor FDA approved for healing diabetic foot ulcerations is recombinant human platelet-derived growth factor-BB (rhPDGF-BB.) Administered in a gel formulation concurrent with a standardized regimen of good wound care, Regranex (generic name becaplermin) gel increases complete wound closure and decreases the time frame for accomplishing wound healing. Regranex normalizes abnormally low levels of PDGF that are present in chronic diabetic ulcerations.

Other factors being investigated for the role they may play in diabetic ulcer formation (and their resolution) include topical bFGF (basic fibroblast growth factor), VEGF (vascular endothelial growth factor) as well as NO (nitrous oxide).

Bullous Diabeticorum

Diabetic bullae are blisters that spring up spontaneously on the hands and feet of diabetics. They are not caused by a bacterial infection of the skin but can be the source of bacterial secondary infection. This makes it vital that wound care receive immediate attention.

Patients prone to diabetic blisters tend to already have signs of diabetic neuropathy. Circulation tends to be normal. The cause of these blisters remains unknown, and therapy is limited to infection prevention. It is recommended that if the blisters are popped (with a sterile needle) and that the skin be left in place to act as a natural bandage. Drying agents like (Polysporin First Aid Antibiotic Ointment) prevents infection. Blisters tend to heal without scar formation provided infection does not occur.

Eruptive Xanthomatosis

Metabolic states associated with diabetes can include high blood fat levels. Eruptive xanthomas are the result of fat laden scavenger skin cells (histiocytes). Yellow waxy bumps form on the bony regions of the arms and legs and behind the knees and soft areas of the forearms. Strict control of blood fats and blood sugar is required for resolution. It is important to realize that not all xanthomas will resolve with nutritional and medicinal control.

Yellow Skin

A medical oddity, diabetics can develop yellow skin and nails without any medically concerning reason. It is suspected that increased levels of beta-carotene or non-enzymatic glycosylation of dermal collagen may be to blame. There is currently no treatment.

Diabetic Scleredema

Diabetics have a predilection to develop thicker skin than those without diabetes. While there are varying forms, the most significant type is clearly associated with diabetes scleredema diabeticorum. Thickening areas of skin form along the back of the neck, the upper back and the upper arms and hands.

The cause of diabetic scleredema is unknown and may be difficult to distinguish from scleroderma without examination under electron microscopy. There seems to be a difference in the material surrounding the enlarged collagen bundles. In scleredema, increased hyaluronic acid is present while in scleroderma there is an increase in dermatan sulfate. Currently there is no known therapy for this disorder, however, tight control of blood sugar may be helpful.

Acanthosis Nigricans

Acanthosis nigricans consists of velvety brown thickened patches commonly found under the arms but may also arise along the neck and flexures. Patients note areas of skin discoloration then followed by a thickening of the skin.

While there are several types of acanthosis nigricans, one form due to insulin resistance seen in noninsulin-dependent diabetics does exist. This lack of response to insulin results in increased levels of the hormone. It is thought that the higher levels of circulating insulin actually triggers skin cell growth factor receptors resulting in cell reproduction. While eradication of this condition is difficult, weight reduction and reducing carbohydrate and sugar intake may play a role in therapy by helping reduce insulin resistance. For troublesome darkness, patients can try thinning the areas with a retinoid such as prescription Tazorac Cream or Retin A and then trying a bleaching agent. Use products carefully. Too much irritation may increase skin discoloration. Stick with a gentle, fragrance-free underarm antiperspirant such as DERMAdoctor Total NonScents Ultra-Gentle Antiperspirant or DERMAdoctor Total NonScents Ultra-Gentle Brightening Antiperspirant.

Perleche

Painful cracking at the corners of the mouth is commonly due to a Candida albicans yeast infection known as perleche. While perleche can be an extension of a localized yeast infection such as thrush (carrying yeast in the mouth or throat), it's more commonly due to systemic disease such as diabetes. Not all perleche sufferers are diabetic nor do they go on to develop diabetes, but this is certainly ruled out in the evaluation of the problem.

Treatment, while simple, may be chronic and is dependent on the particular individual. Prescription products such as Nystatin Oral Suspension is swished around the mouth and also applied to the angles of the mouth perhaps 3-4 times daily until clear. Maintenance may be required once or twice a day thereafter.

Intertrigo

Intertrigo affects the health of skin hidden by heavy body folds. Heat and humidity along with darkness combine to create the proper conditions for yeast (Candida albicans) to thrive. The result is intertrigo. Intertrigo tends to flare each summer, since the environmental factors play such an important role. Regions most prone include skin folds under the breasts, abdomen as well as the thighs and pubic region.

Intertrigo symptoms include redness, scaling and significant itching. Raw spots may also develop, and tiny, red bumps and pustules may be present. Frequently the entire affected area is a sheet of redness.

In diabetes, high blood sugar is an additional impetus for yeast to flourish. Treatment is aimed at controlling blood sugar, eradicating the infection and creating an environment unfriendly to Candida. Failure to follow through may result in a chronic condition. Gain control by following these three principles:

• Dry It
• Treat It
• Prevent It

The last thing you want to do is apply tons of goopy wet creams or ointments to the area; this is just going to make the area ripe for further flare-ups. I like using a prescription medicated powder called Mycostatin Powder and have my patients apply it 3-4 times a day if possible. The powder helps keep the area dry as well as kills the yeast. Mycostatin powder can be used on a maintenance basis to help prevent intertrigo when regular powders don't work.

If another yeast killing product is required, prescription Nizoral Cream is ideal. Keep two things in mind: I sometimes find that this product can be irritating, particularly for anyone with a very inflamed case. Also, whatever cream you are going to apply should be used sparingly and rubbed into the skin leaving no surface trace of it. The last thing needed is more moisture here!

For resistant cases, the use of an oral anti-yeast medication such as Diflucan can be used. However, short of killing the yeast, this does little to help many of the skin changes. Either the Mycostatin Powder or Zeasorb-AF Antifungal Powder should be used frequently to help keep moisture at bay and treat surface yeast, too. Zeasorb-AF Antifungal Drying Gel is unique, as it comes in an alcohol base so it helps dry the moisture away and leaves a medicated powder behind. Don't apply this base to raw skin!

After bathing, use of a hand held hair dryer placed on the cool setting prior to applying medicated powders is a great way to hasten control.

Advanced cases with weeping or raw areas will need additional loving care here. Understandably the skin will likely be quite sensitive and perhaps painful. Make certain you are not wearing clothing that may rub the area raw. Avoid wearing bras if you are to this point until the situation is under control. The use of astringent drying agents like Domeboro Astringent Solution can be applied with a moist washrag for 20 minutes twice a day. Treat raw spots with tiny dabs of antibiotic ointment like Polysporin First Aid Antibiotic Ointment. Another product, colorless Castellani's paint, is great for exuberant amounts of oozing. It is simply painted onto the area and helps to dry and kill some of the bacteria that tend to take advantage of broken skin.

Wait a few days until the oozing is under control before trying to apply creams. You can try the application of your medicated powder, but again, you may have to wait until the moisture has been reduced.

A simple way to help heal intertrigo, regardless of severity is to stay cool as a cucumber by allowing air to circulate around the affected region. Twice a day, lift up area (abdominal fold, breast, etc.), and allow air to access skin folds. Ideally allow for 10 minutes. Remember, this seems like a long time when you are standing around, so make sure you check the clock.

You may not have a choice about having diabetes, but don't let diabetes get your skin down. Vigilant monitoring and tender loving care can help keep your skin looking healthy and radiant.

Thank you for reading my article on diabetes and skin care. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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