Cutaneous manifestations of diabetes mellitus

Electrospun membranes chelated by metal magnesium ions enhance pro-angiogenic activity and promote diabetic wound healing

Diabetic wounds, resulting from skin atrophy due to localized ischemia and hypoxia in diabetic patients, lead to chronic pathological inflammation and delayed healing. Using electrospinning technology, we developed magnesium ion-chelated nanofiber membranes to explore their efficacy in antibacterial, anti-inflammatory, and angiogenic applications for wound healing. These membranes are flexible and elastic, resembling native skin tissue, and possess good hydrophilicity for comfortable wound bed contact. The mechanical properties of nanofiber membranes are enhanced by the chelation of magnesium ions (Mg2+), which also facilitates a long-term slow release of Mg2+. The cytocompatibility of the nanofibrous membranes is influenced by their Mg2+ content: lower levels encourage the proliferation of fibroblasts, endothelial cells, and macrophages, while higher levels are inhibitory. In a diabetic rat model, magnesium ion-chelated nanofibrous membranes effectively reduced early wound inflammation and notably accelerated wound healing. This study highlights the potential of magnesium ion-chelated nanofiber membranes in treating diabetic wounds.

Exploration of Potential Biomarkers for Type 2 Diabetes by UPLC-QTOF-MS and WGCNA of Skin Surface Lipids

BACKGROUND

Diabetes has become popular and has become one of the most important global health care challenges. Patients with diabetes have a high incidence of skin diseases. Cell and animal models are often used to study the skin conditions of people with diabetes.

METHODS

In this study, a volunteer questionnaire survey, skin lipomics analysis based on ultra-high performance liquid chromatography-quadrupole tandem time-of-flight mass spectrometry (UPLC-QTOF-MS), and weighted gene co-expression network analysis (WGCNA) were used to study the differences in skin conditions and skin lipids of participants with type 2 diabetes mellitus (Group D) versus healthy individuals (Group H) and the correlation between these groups. The questionnaire was used to investigate personal basic, diabetes, and facial skin status information of 77 female volunteers aged 55-65 years old from the Peking University Shougang Hospital. The facial skin lipids of all volunteers were analysed by UPLC-QTOF-MS technique; the differential lipids between groups D and H were analysed by partial least-squared discriminant and univariate analysis.

RESULTS

In total, 23 kinds of differential lipids were identified, all of which belonged to sphingolipids. The use of WGCNA combined clinical information with lipid analysis to study the relationship between glycosylated haemoglobin, skin pigmentation/non-pigmentation, and skin lipids. Two types of lipids were identified to distinguish between hub lipids of high and low glycosylated haemoglobin; 12 types of lipids were identified that could distinguish between the hub lipids of pigmented and non-pigmented participants (PLS-DA).

CONCLUSION

The experimental results not only provide a reference for the diagnosis and classification of diabetes via analysing the skin lipids of patients, but also provides a theoretical basis for further study on the effects of diabetes on the skin of patients.

The impact of diabetes mellitus on medical complication and mortality rates among inpatients with bullous pemphigoid

BACKGROUND

There is currently limited population-based data on the effect of type 2 diabetes mellitus (T2DM) on bullous pemphigoid (BP) inpatients.

AIMS

To evaluate the relative comorbidities, medical complications, and mortality rates between BP inpatients with and without T2DM.

METHODS

All inpatients with a primary BP diagnosis in the National Inpatient Sample from 2003 to 2012 were queried. BP inpatients with or without T2DM were compared to identify disparities in relative comorbidities and medical complications. Comorbidities were established using the Agency for Healthcare Research and Quality standardized values. Medical complications were classified using ICD-9 codes.

RESULTS

Of the 1978 BP patients identified, 660 (33.4%) had a concurrent diagnosis of T2DM. These patients had significantly higher rates of concurrent comorbidities, including chronic renal failure, congestive heart failure, iron deficiency anemia, hypertension, obesity, and peripheral vascular disease. On bivariate analysis, T2DM patients also had significantly higher rates of medical complications including acute kidney injury (14.5% vs. 10.1%, p = 0.004) and venous thromboembolism (1.8% vs. 0.5%, p = 0.012). On multivariable-adjusted analysis, the odds of venous thromboembolism (OR = 3.01, p = 0.027) remained increased. Inpatient mortality did not differ between the groups.

CONCLUSIONS

Our findings suggest that BP inpatients with T2DM have a greater medical comorbidity and complication burden. However, inpatient mortality was not increased.

Cutaneous, genital and oral lichen planus: A descriptive study of 274 patients

Background

Lichen planus (LP) is a chronic autoimmune disease that affects the oral mucosa as well as the skin, genital mucosa and other sites. Objective: to evaluate the correlation between oral, genital and cutaneous lichen planus, in a sample of LP patients.

Material and Methods

This descriptive study reviewed 274 clinical histories of patients, who all presented histological confirmation of lichen planus verified by a pathologist, attending research centers in Barcelona.

Results

A total of 40 LP patients (14.59%) presented genital lesions. Of 131 patients with cutaneous LP (47.8%), the most commonly affected zones were the body’s flexor surfaces, representing 60.1% of cases. 24% of patients (n=55) related the start of the lesions with previous stress events. Of the 131 subjects with cutaneous lesions, 19% (n=25) also presented oral lichen planus (OLP). Of the total sample, 53.6% (n=147) of patients presented oral lesions. The systemic diseases most commonly associated with this patient sample were psychological problems such as stress, anxiety and depression (48%), hypertension (27%), gastric problems (12%), and diabetes (9.7%). A family history of lichen planus was found in only 2 cases (0,72%) out of the total of 274.

Conclusions

Any patient with OLP should undergo a thorough history and examination to investigate potential extraoral manifestations. The fact that 37 patients with OLP in this patient series were identified with simultaneous involvement at more than one site highlights the need for thorough evaluation and multidisciplinary approaches to this disease.

Key words:Oral lichen planus, extra-oral manifestations, cutaneous lichen planus, genital lichen planus.

Oral lichen planus and its relationship with systemic diseases. A review of evidence

BACKGROUND

Oral lichen planus (OLP) is one of the most common dermatological diseases which are present in the oral cavity. It is a chronic autoimmune, mucocutaneous disease that affects the oral mucosa as well as the skin, genital mucosa and other sites.

OBJECTIVE

Review the relevant information to OLP and its relationship with systemic diseases.

MATERIAL AND METHODS

Searches were carried out in the Medline/PubMed, Lilacs, Bireme, BVS, and SciELO databases by using key-words. After an initial search that provided us with 243 papers, this number was reduced to 78 from the last seven years. One of the first criteria adopted was a selective reading of the abstracts of articles for the elimination of publications that presented less information regarding the subject proposed for this work. All the selected articles were read in their entirety by all of the authors, who came to a consensus about their level of evidence. The Scottish Intercollegiate Guidelines Network (SIGN) criteria were used as the criteria of methodological validation.

RESULTS

Only 9 articles showed an evidence level of 1+, 2+, 3 or 4, as well as a recommendation level of A, B, C or D. Three of them were non-systematic reviews, one was a cohort study and only one was a controlled clinical trial. Three of the studies were case series, with respective sample sizes of 45, 171 and 633 patients.

CONCLUSIONS

Several factors have been associated with OLP. Patients with OLP are carriers of a disease with systemic implications and may need the care of a multidisciplinary team. The correct diagnosis of any pathology is critical to making effective treatment and minimizes iatrogenic harm. For OLP is no different, taking into account its association with numerous systemic diseases that require special attention from health professionals. Periodic follow-up of all patients with OLP is recommended. Key words:Oral lichen planus, etiopathogenesis, systemic diseases.

Abnormal skin in toe webs is a marker for abnormal glucose metabolism. A cross-sectional survey among 1,849 adults in Finland

Diabetes is undiagnosed disease and easy screening tools for it are warranted. Because foot complications are usual in diabetes, we aimed to test hypothesis that skin abnormalities are found already from patients who are not aware of having diabetes, by studying the possible association between unhealthy toe web skin and abnormal glucose metabolism. 1,849 cases without previously diagnosed diabetes participated to the 46-year follow-up study of the Northern Finland Birth Cohort. A skin investigation was performed for all, and abnormal skin findings in toe web spaces were taken as explanatory variables. Abnormal glucose tolerance was the main outcome and it was tested with an oral glucose tolerance test (OGTT), glycosylated haemoglobin fraction (HbA_1c) Values are numbers (percentages) of sub and fasting blood glucose. The participants who had any abnormal skin findings in toe webs were associated with 2.5-fold (OR 2.5, 95% CI 1.3–4.9) and 6-fold (OR 6.2, 1.4–27.6) increased risk of having previously undiagnosed diabetes detected by a 2-hour OGTT and HbA_1c, respectively. The predictive power of toe web findings was comparable with FINDRISC score. Abnormal skin findings in the toe webs show increased risk of occult diabetes, and may, thus serve as an additional sign of undiagnosed diabetes.

The skin remodeling in type 1 diabetes and insulin resistance animal models

The skin matrix metalloproteinase 3, tissue inhibitors of matrix metalloproteinase 2 and collagen III content changes in type 1 diabetes and insulin resistance treated with insulin and metformin were studied. Healthy adult male Wistar rats were obtained from experimental animal house, Department of Experimental Pharmacology, Medical University in Bialystok. The rats were divided randomly into five groups of 8 rats each. Control rats were injected intraperitoneally by NaCl. Type IDDM was induced by a single injection of Streptozocin. Insulin resistance was induced by a high-fat diet. The chosen groups of rats were also treated with insulin or metformin. ELISA Kits (USCN Life Science, China) were used to measure content of matrix metallo-proteinase 3 (ELISA Kit for Matrix Metalloproteinase 3 - MMP3), tissue inhibitor of matrix metalloproteinase 2 (ELISA Kit for Tissue Inhibitors of Metalloproteinase 2 - TIMP2) and content of collagen type 3 (ELISA Kit for Collagen Type III - COL3). The results were reported as a median. The statistical significance was defined as p<0.05. Type 1 diabetes and insulin resistance have significantly reduced the quality of the skin, shown by the increase in content of matrix metalloproteinase 3 and the decrease in content of tissue inhibitors of matrix metalloproteinase 2. Type 1 diabetes and insulin resistance have reduced the quality of the skin expressed by type III collagen content decrease but for future studies it is recommend to determine rat interstitial collagenase, MMP-13, as well. Insulin and metformin treatment improved the quality of the diabetic skin, demonstrated by the type III collagen content increase.

Bullosis diabeticorum in median nerve innervated fingers shortly after carpal tunnel release: case report

Bullosis diabeticorum is a cutaneous manifestation of diabetes mellitus, mainly observed in the lower extremities in patients with longstanding disease. The etiology is unknown, but an association with neurologic or vascular disturbances has been suggested. We have reviewed a case of a 70-year-old man with rapid development of bullae in median nerve innervated fingertips following carpal tunnel release.

Skin pH is lower in type 1 diabetes subjects and is related to glycemic control of the disease

BACKGROUND

Diabetes is a systemic disease affecting many organs, including skin. Skin may reflect the condition of internal organs. The aim of our study was to measure skin pH in type 1 diabetes mellitus (T1DM) patients and in healthy controls and to evaluate the association between metabolic control of diabetes and skin acidity in T1DM patients.

MATERIALS AND METHODS

The study was conducted on 105 patients with T1DM and 53 age- and sex-matched healthy people. Skin surface pH was measured in three different areas of the body (cheek, forearm, and foot) in diabetes patients and healthy controls. The results were compared for patients' and controls' clinical characteristics and for patients' metabolic control and also evaluated according to the presence of complications of diabetes.

RESULTS

Patients with T1DM had lower skin pH compared with the control group in three measured areas: within the cheek (5.49 ± 0.42 vs. 5.69 ± 0.31; P = 0.001), forearm (5.41 ± 0.46 vs. 5.73 ± 0.69; P = 0.004), and foot (5.20 ± 0.53 vs. 5.41 ± 0.41; P = 0.008). In the multiple linear regression skin pH was negatively correlated with fasting plasma glucose on the cheek (β = -0.34, P = 0.0004), forearm (β = -0.30, P = 0.0009), and foot (β = -0.18, P = 0.04). Diabetes patients with glycated hemoglobin (HbA1c) ≥ 8% had significantly lower skin pH than patients with better glycemic control (HbA1c < 8%). However, we observed a statistically significant difference only on the foot (5.09 ± 0.50 vs. 5.34 ± 0.55; P = 0.019).

CONCLUSIONS

Skin surface pH is lower in individuals with diabetes, and it is negatively related to actual and chronic hyperglycemia.

Prevalence and risk of appearence of skin lesions considered to be cutaneous markers of diabetes in a population group in bihor county

Objectives: The aim of the study was to calculate the prevalence rates and risk ofappearance of cutaneous lesions in diabetic patients with both type-1 and type-2diabetes. Material and Method: 384 patients were analysed, of which 47 had type-1diabetes (T1DM), 140 had type-2 diabetes (T2DM) and 197 were non-diabeticcontrols. Results: The prevalence of the skin lesions considered markers of diabeteswas 57.75% in diabetics, in comparison to 8.12% in non-diabetics (p<0.01). The riskof skin lesion appearance is over 7 times higher in diabetic patients than in nondiabetics.In type-1 diabetes the prevalence of skin lesions was significantly higherthan in type-2 diabetes, and the risk of skin lesion appearance is almost 1.5 timeshigher in type-1 diabetes than type-2 diabetes compared to non-diabetic controls.Conclusions: The diabetic patients are more susceptible than non-diabetics todevelop specific skin diseases. Patients with type-1 diabetes are more affected.

Dermatologic manifestation of diabetes

With the rising incidence of diabetes mellitus (DM) in the US, it is of paramount importance that practitioners understand the complications of DM and how best to manage them. Diabetes affects every organ system and the skin is no exception. There are numerous cutaneous manifestations of DM that have similar etiologies and result from the same pathologic mechanisms as the internal complications of this disease state. In addition, skin manifestations may precede the diagnosis of diabetes. The present article reviews both the common and less common cutaneous manifestations of DM, including presenting lesions, pathogenesis, and management.

Effects of diabetes and/or hypercholesterolemia on skin development of rat fetuses

OBJECTIVE

To investigate the effects of diabetes and/or hypercholesterolemia on skin development during in utero life at 15, 17 & 19 days old.

METHODS

Sixty pregnant female albino Wistar rats were arranged into three groups: control, diabetic (single i.p. 60 mg streptozotocin/kg B.wt) and hypercholesterolemic (diet supplement 3% cholesterol 6 week prior to conception and throughout gestation). Pregnant rats were sacrificed at 15, 17 & 19 days prenatal). Vibrissae skin biopsies were removed and allowed for scanning (SEM), light, and transmission electron microscopic (TEM) investigation. Also, DNA fragmentation and sodium dodecyl polyacrylamides gel electrophoresis (SDS-PAGE) were carried out.

RESULTS

Scanning electron microscopic observations revealed retarded hair follicle growth and deformations of their pattern structure. At light microscopic level, skin exhibited decreased epidermal cornification, as well as degeneration of hair follicles in fetuses of both diabetic and hypercholesterolemic groups. Transmission electron microscopy revealed abundant vacuolar spaces in the epidermis. Degenerative phases become more abundant in keratinocytes as well as in stratum germinativum cells. Fetal skin possessed altered protein expression and missing bands as well as separation of genomic DNA to several degraded bands in skin of 15-, 17-, and 19-day-old, maternally diabetic and/or hypercholesterolemic fetuses.

CONCLUSION

These findings showed that maternal diabetes and/or hypercholesterolemia increased average deformation of hair follicles, vacuolation, and degeneration of epidermal cell layers. The observed findings resulted from altered protein expression and increased DNA fragmentation, which, in turn, disrupt epidermal cell differentiation.

Skin blood flow abnormalities in diabetic dermopathy

BACKGROUND

Diabetic dermopathy is the most common specific cutaneous finding in diabetes.

OBJECTIVE

Using laser Doppler technology, we tested the hypothesis that diabetic dermopathy arises from abnormal local skin blood flow.

METHODS

We measured cutaneous blood flow in patients with type 1 diabetes without dermopathy and compared values with those in a control group of patients with type 1 diabetes without diabetic dermopathy and in a nondiabetic group. We measured at 3 separate sites on the pretibial area on the legs of each participant, at dermopathy lesions, and at a number of standard sites on the upper and lower extremities.

RESULTS

We studied 25 patients with diabetes and diabetic dermopathy, average age 51 ± 2 years, mean duration of diabetes 28 ± 3 years. In all, 58 patients with type 1 diabetes without diabetic dermopathy served as control patients, average age 41 ± 2 years, mean duration of diabetes 23 ± 2 years. There were 67 nondiabetic control subjects, average age 47 ± 3 years. The patients with diabetic dermopathy showed a marked reduction in skin blood flow at 35°C at normal-appearing skin areas on the pretibial surface of the legs (1.1 ± 0.1 mL/min/100 g) compared with 1.7 ± 0.1 mL/min/100 g (P = .01) in the type 1 diabetic control group and 2.1 ± 0.3 mL/min/100 g (P < .01) in the nondiabetic group. The dermopathy lesions themselves showed markedly higher blood flow: 2.5 ± 0.3 mL/min/100 g.

LIMITATIONS

Our diabetic dermopathy patients were somewhat older than the control type 1 diabetes subjects, but were of comparable age to the nondiabetic subjects.

CONCLUSIONS

These results suggest that patients susceptible to diabetic dermopathy have a functional abnormality in blood flow leading to this scarring process.

Diagnostic dilemma of a subcutaneous nodule following a trauma in a child: immunohistochemical examination put the final diagnosis of deep granuloma annulare

The diagnostic dilemma is discussed on a child who presented a granulomatous process of the inferior limb following a trauma. It was originally considered epithelioid sarcoma (ES) and later diagnosed as deep granuloma annulare (DGA). In combination with the clinical assessment, the plain radiographs, the ultrasound and the magnetic resonance proved inadequate in reaching diagnosis and in excluding neoplasia. Biopsy was required, and the following immunohistochemical examination put the definitive diagnosis of deep granuloma annulare. Development of DGA after trauma seems to be rare, but it is a possible event and further observations are needed to explain the triggering roles in the etiopathogenesis of this disease.

Cutaneous manifestations of diabetes. Signs of poor glycemic control or new-onset disease

Diabetes attacks multiple organ systems, and the skin is not spared its detrimental effects. Pathologic consequences of diabetes, such as vasculopathy, neuropathy, immunologic disturbances, defects in collagen formation, and poor glycemic control, contribute to its numerous cutaneous manifestations. In this article, Drs Tabor and Parlette present the implications of, and treatment options for, infections and dermatoses that appear in established diabetes or that indicate new-onset disease. They also discuss diabetes medications that commonly cause cutaneous reactions.

The prevalence of diagnosed cutaneous manifestations during ambulatory diabetes visits in the United States, 1998-2002

BACKGROUND

The prevalence of diabetes has been rapidly increasing. Previous reports indicated that diabetics are prone to certain cutaneous diseases.

OBJECTIVE

To determine the frequencies of diagnosed skin conditions during ambulatory diabetes visits in the USA.

METHODS

We evaluated two national ambulatory medical care surveys between 1998 and 2002 and compared the diagnoses of 7 categories of skin conditions in diabetics (n = 9,626) to patients with hypertension (n = 15,997) or gastroesophageal reflux disease (GERD; n = 2,362) using chi2 tests and multivariate logistic regressions.

RESULTS

Diabetics were prone to chronic skin ulcers (odds ratio = 62.5, 95% confidence interval = 3.95-989 compared to GERD; 9.97, 6.34-15.7 compared to hypertension), bacterial skin infections (5.95, 2.86-12.4 compared to GERD; 5.15, 3.74-7.08 compared to hypertension) and fungal skin infections (2.66, 1.15-6.16 compared to GERD; 1.99, 1.32-3.01 compared to hypertension) but not to other skin conditions. These findings remained true during primary care physician visits.

CONCLUSION

Chronic skin ulcers, bacterial and fungal skin infections are more frequently diagnosed in diabetics. We could not verify that other skin conditions are associated with diabetes, in part due to potential underdiagnosis and underreporting.

Long-term results of topical PUVA in necrobiosis lipoidica

The aim of our study was to evaluate the long-term results of topical psoralen ultraviolet A (PUVA) in patients with necrobiosis lipoidica (NL), in whom conventional methods (pentoxifylline, vitamin E, tretinoin, and topical or intralesional corticosteroids) had failed. The study comprised 10 women (age range 17-44 years), six of whom were insulin-dependent diabetics and four were diabetes-free. Duration of NL ranged from 3 to 10 years. The patients were treated with a 0.005% aqueous solution of 8-methoxypsoralen, applied topically for 30 min, and subsequently irradiated with UVA three times weekly. All the patients experienced almost complete remission (softening of skin lesions, no hyperpigmentation, lack of lesion progression) after a mean of 47 sessions (mean UVA cumulative dose 69.5 J/cm2). They were followed up for 12-24 months, during which time two recurrences, both in diabetic patients, were observed after 8 and 12 months of treatment cessation, which further resolved after another course of topical PUVA. We conclude that topical PUVA is well tolerated by NL patients and may serve as an alternative therapeutic regimen.

Cutaneous manifestations of diabetes mellitus. Study from Farwaniya hospital, Kuwait

OBJECTIVE

To study the prevalence of cutaneous disorders in patients with diabetes mellitus.

SUBJECTS AND METHODS

All diabetic patients attending the Department of Dermatology, Al-Farwaniya Hospital, Kuwait, and diabetic in-patients with skin disorders were examined over a period of 18 months from March 2004 to August 2005. A total of 106 diabetic patients displaying 1 or more dermatological manifestations were identified and thoroughly examined for any skin disorder. The diabetic profile of the patients was obtained from medical records.

RESULTS

Of the 106 patients, 69 had only 1 cutaneous manifestation, 27 had 2, 6 had 3 and 4 had 4. Infections (68.0%) were the major cutaneous manifestations with fungal infection occurring in 41 patients followed by bacteria in 27. The second most common presenting symptom was pruritus. Hypertension (74%) was the most common systemic complication, and most of the diabetic patients who developed cutaneous manifestations were in the 40- to 60-year age group.

CONCLUSIONS

The data show that infections were the most common cutaneous manifestation and hypertension the most common systemic complication.

Light-chain-restricted plasmacellular infiltrates in necrobiosis lipoidica -- a clue to an underlying monoclonal gammopathy

BACKGROUND

Necrobiosis lipoidica (NL) is a member of the palisading granulomatous dermatitides that is associated, in most cases, with diabetes mellitus. However, there are an increasing number of cases of NL associated with other forms of systemic disease. We describe a novel case of NL associated with a light-chain-restricted plasmacellular infiltrate; subsequent investigations established an underlying monoclonal gammopathy.

METHODS

Skin biopsy material was obtained and was processed in the usual fashion for hematoxylin and eosin (H and E) examination. Immunohistochemical staining was performed by utilizing kappa and lambda monoclonal antibodies (Dako Corporation, Carpentiera, CA, USA). Kappa and lambda in situ hybridization was also performed (Ventana Medical Systems, Tucson, AZ, USA).

RESULTS

A 55-year-old woman with a 5-year history of bilateral thigh subcutaneous nodules underwent a skin biopsy, showing typical changes of NL; there was a concomitant prominent perivascular plasmacellular infiltrate. Kappa light chain restriction was observed amid the plasmacellular infiltrate. Bone marrow biopsy and immunophenotyping studies revealed a clonal plasmacytosis with kappa light chain restriction.

CONCLUSIONS

Granulomatous inflammation, including NL, may be a cutaneous paraneoplastic expression of low-grade B-cell lymphoproliferative disease in the context of an underlying plasma cell dyscrasia.

[Skin changes in diabetes mellitus]

Diabetes mellitus is the most frequent metabolic disorder. Just under 5 million people suffer from this disease in Germany. Four types of diabetes mellitus are distinguished: type 1 diabetes, type 2 diabetes, other specific diabetes forms, and gestational diabetes. Many characteristics of diabetes mellitus including skin changes are already manifest in the "prediabetic" stage when glucose tolerance is limited so that every elevation of blood sugar levels must be considered pathological. Changes in skin due to diabetes mellitus can be categorized into four disease groups: skin infections, skin diseases found overly frequently in association with diabetes mellitus, skin alterations due to diabetic complications, and reactions to antidiabetic treatment.

Collagenolytic (necrobiotic) granulomas: part II - the ‘red’ granulomas

A collagenolytic or necrobiotic non-infectious granuloma is one in which a granulomatous infiltrate develops around a central area of altered collagen and elastic fibers. The altered fibers lose their distinct boundaries and exhibit new staining patterns, becoming either more basophilic or eosinophilic. Within the area of altered collagen, there may be deposition of acellular substances such as mucin (blue) or fibrin (red), or there may be neutrophils with nuclear dust (blue), eosinophils (red), or flame figures (red). These color distinctions can be used as a simple algorithm for the diagnosis of collagenolytic granulomas, i.e. 'blue' granulomas vs. 'red' granulomas. Eight diagnoses are included within these two groupings, which are discussed in this two-part article. In the previously published first part, the clinical presentation, pathogenesis and histologic features of the 'blue' collagenolytic granulomas were discussed. These are the lesions of granuloma annulare, Wegener's granulomatosis, and rheumatoid vasculitis. In this second half of the series, the 'red' collagenolytic granulomas are discussed; these are the lesions of necrobiosis lipoidica, necrobiotic xanthogranuloma, rheumatoid nodules, Churg-Strauss syndrome, and eosinophilic cellulitis (Well's Syndrome).

Cutaneous manifestations of endocrine-metabolic disease and nutritional deficiency in the elderly

This article explores cutaneous manifestations of endocrine-metabolic disease and nutritional deficiency in the elderly. Topics covered include the following: diabetes mellitus, thyroid disorders, adrenal dysfunction, pituitary disorders, parathyroid disease, nutritional deficiencies, menopause, and HIV.

A reappraisal of the histologic findings of pigmented pretibial patches of diabetes mellitus

BACKGROUND

Pigmented pretibial patches (PPPs) are the most common cutaneous alterations in diabetes mellitus, found in up to 50% of diabetic patients. They classically present as flat-topped, dull-red papules on the pretibial areas, later becoming hyperpigmented and atrophic. Little is known regarding the pathogenesis of these lesions, and the histopathologic findings have been regarded as non-specific.

METHODS

We investigated the clinical and pathologic attributes of a series of 12 diabetic patients with PPP in an effort to discern any specific histologic attributes compared to normal skin removed from diabetic patients with cutaneous carcinoma.

RESULTS

All cases of PPP showed hyaline microangiopathy, all patients showed extravasated erythrocytes and/or hemosiderin deposits, and 10 patients showed an appreciable number of perivascular plasma cells. The average number of plasma cells per vascular plexus was 2.2. Control specimens removed from five diabetic patients showed hyaline microangiopathy, and three showed extravasated erythrocytes and hemosiderin. One patient showed a single vascular plexus with two plasma cells, p = 0.01.

CONCLUSION

The presence of increased dermal perivascular plasma cells in the appropriate clinical context might be an important and under-recognized clue for PPP. The pathogenic significance of this finding is unknown.

Diabetes mellitus e afecções cutâneas

O diabetes mellitus é doença metabólica que predispõe a diversas afecções, notadamente às doenças cutâneas. São de natureza variada, porém de etiologia infecciosa em sua maioria. Uma revisão detalhada sobre tais doenças, evidenciando suas características clínicas bem como uma adequada abordagem terapêutica é o tema do presente artigo.

Treatment of necrobiosis lipoidica with topical psoralen plus ultraviolet A

BACKGROUND

Necrobiosis lipoidica (NL) is a rare skin disease, mostly seen on the legs and often occurring in patients with diabetes mellitus. The disease belongs to the idiopathic cutaneous palisading granulomatous dermatitides associated with a degeneration of collagen, thus leading to skin atrophy. Application of topical corticosteroids is the most widely used treatment but the results are not always satisfactory and may worsen skin atrophy. Preliminary studies in patients with NL have shown a clinical response with psoralen plus ultraviolet (UV) A (PUVA). Objectives To study the effect of topical PUVA on NL in a multicentre prospective study.

METHODS

Thirty patients (27 women and three men) including 13 with insulin-dependent diabetes mellitus, with a diagnosis of NL proven by histopathology, were included. All patients had been unsuccessfully treated with topical and/or intralesional corticosteroids. Patients were treated twice weekly with an aqueous gel containing 0.005% psoralen followed by irradiation with UVA. Clinical photographs were taken for evaluation. In addition, 20-MHz high-frequency ultrasound analysis was performed in 10 patients to evaluate the thickness and density of the dermis during topical PUVA therapy.

RESULTS

Five patients (17%) showed complete clearing (healing of ulceration and disappearance of erythema) after a mean of 22 exposures (range 15-30). Eleven patients (37%) showed improvement, defined as healing of ulceration and/or reduction of erythema, after a mean of 23 exposures (range 11-42). Ten patients (33%) showed no effect and four patients (13%) worsened during topical PUVA therapy. The treatment results of the patients who suffered from diabetes mellitus were not different from those who did not have diabetes mellitus. No difference was seen in mean dermal thickness (1666 vs. 1706 micro m) and density (17 vs. 16 units) before and after topical PUVA therapy. Side-effects were seen in 10 patients: hyperpigmentation (n = 4), blistering (n = 4) and bacterial infection (n = 2).

CONCLUSIONS

Topical PUVA may be a useful treatment modality for NL in patients not responding to topical or intralesional corticosteroids.

Cutaneous manifestations of diabetes mellitus

Diabetes is a common disease with many cutaneous manifestations encountered by dermatologists. Diabetes and the skin may be linked by association (e.g., necrobiosis lipoidica); infection; diabetic complication (e.g., neuropathic ulcer); or treatment reaction. Review of recent studies and reports focuses on pathogenesis and treatment of these many diabetic cutaneous changes.

Lack of an association between granuloma annulare and type 2 diabetes mellitus

BACKGROUND

Conflicting reports have been published regarding whether a relationship exists between granuloma annulare (GA) and diabetes mellitus (DM).

OBJECTIVES

To evaluate the prevalence of DM in patients with GA using a case-control design.

METHODS

The incidence of DM was determined in 126 patients with GA. Fifty of the 126 patients with GA were further compared with an age-, sex- and race-matched population of psoriasis patients seen during a similar time period in the same clinical setting.

RESULTS

Eleven (9%) of 126 GA patients suffered from type 2 DM. In the matched comparison of 50 patients, 11 (22%) GA patients and 10 (20%) psoriasis patients suffered from type 2 DM.

CONCLUSIONS

This case-control study failed to reveal any statistically significant correlation between GA and type 2 DM.

Subcutaneous granuloma annulare in childhood: clinicopathologic features in 34 cases

OBJECTIVE

To gather clinicopathologic data on subcutaneous granuloma annulare (SGA), a subtype of granuloma annulare that occurs exclusively in children and is histologically similar to rheumatoid nodules.

DESIGN

Retrospective record review.

PATIENTS

Children <10 years old in whom SGA, deep granuloma annulare, or necrobiotic granuloma was diagnosed at the Mayo Clinic (Rochester, MN) from 1983 to 1998.

RESULTS

Thirty-four patients (21 girls and 13 boys; average age at diagnosis: 4.6 years) were found to have SGA. The lesions predominantly occurred in the lower extremity, especially in a pretibial location. Local recurrence within 1 month to 7 years was documented in 38.2%; recurrence at other locations was documented in 14.7%. Average follow-up was 60 months; during follow-up, no patients developed signs or symptoms of rheumatologic disease. Insulin-dependent diabetes mellitus was diagnosed in 2 patients, 1 before the development of SGA and 1 after it by 1 month.

CONCLUSIONS

SGA is a lesion that presents as subcutaneous nodules on the lower extremities, hands, or scalp in young children. Recurrence is common but usually does not warrant additional biopsy.

An unusual form of generalized granuloma annulare in a patient with insulin-dependent diabetes mellitus

The generalized form of granuloma annulare may be associated with systemic disorders, including diabetes mellitus. We describe here an unusual form of generalized granuloma annulare in a patient with complicated insulin-dependent diabetes mellitus. The cutaneous eruption had been present for decades as non-pruritic, persistent, violet-brown patches with raised edges. There were flexion deformities of the small joints of the hands and feet associated with thickening of the skin over dorsa of the fingers. The patient is currently on isotretinoin therapy, with partial resolution of lesions at 3 months follow-up.

Management of leg ulcers

Leg ulcer is a leading cause of morbidity among older subjects, especially women in the Western world. About 400 years BC, Hippocrates wrote, "In case of an ulcer, it is not expedient to stand, especially if the ulcer be situated on the leg". Hippocrates himself had a leg ulcer. The best treatment of any leg ulcer depends upon the accurate diagnosis and the underlying aetiology. The majority of leg ulcers are due to venous disease and/or arterial disease, but the treatment of the underlying cause is far more important than the choice of dressing. The aetiology, pathogenesis, treatment, and the future trends in the management of the leg ulcers are discussed in this review.

Diabetic bullae: 12 cases of a purportedly rare cutaneous disorder

BACKGROUND

Spontaneous bullae are a characteristic type of skin lesion occurring in patients with diabetes mellitus. These diabetic bullae are considered to be a rare phenomenon; only about 100 cases have been described in the literature since the disorder was first reported 70 years ago.

METHODS

We collected a series of patients with diabetic bullae who were referred to us at a Veterans Affairs Medical Center Clinic specializing in diabetic foot problems. We then reviewed the medical literature for similar cases and summarized the available information.

RESULTS

We saw 12 patients with typical diabetic bullae over an 8-year period in our clinic. The clinical presentation and outcome of the lesions in these patients were similar to those in previously reported cases. The patients were mostly elderly, all but one had lesions located on the lower extremities, all had peripheral neuropathy, two had secondary staphylococcal infection of their bullae, and in all patients the lesions healed without scarring. Although most of the patients had had previous similar lesions, the diagnosis of diabetic bullae had not been previously reported in any of them.

CONCLUSIONS

We have reviewed the clinical syndrome of diabetic bullae and presented brief clinical details of these cases; we offer several vignettes and photographs of these lesions to remind clinicians of what we believe is a not so rare cutaneous disorder.

Coexisting morphoea and granuloma annulare-are the conditions related?

Granuloma annulare and localized morphoea are both well described in the dermatological literature. We now present two patients with both of these diseases, a comorbidity rarely described. A possible pathogenic relationship is discussed.