Skin Complications in Diabetes
Diabetes mellitus is a group of metabolic disorders that involve hyperglycemia as their primary feature. If uncontrolled, chronic hyperglycemia leads to microvascular, macrovascular, and neuropathic complications. Immune dysfunction, diabetic neuropathy and poor circulation in patients with diabetes mellitus put these patients at a higher risk for many types of infections with complicated skin and soft-tissue infections being of the utmost concern. Peripheral neuropathy causes decreased pain sensation and a higher pain threshold in the extremities which leads to increased skin breakdown giving rise to increased skin infection rates.
Peripheral vascular disease (PVD) is a main complication of diabetes and causes decreased blood flow to the extremities. Hyperglycemia impairs nitric oxide-mediated vasodilation and enhances the formation of advanced glycation endproducts (AGEs), leading to increases in pro-inflammatory factors. This results in accelerated atherogenesis and diabetic atheropathy leading to PVD. When patients with diabetes and PVD are diagnosed with a complicated skin and soft-tissue infection, the outcomes are poor. This is due to inadequate tissue perfusion leading to poor antibiotic penetration. About one third of patients with diabetes have a skin disorder whether it be infectious or noninfectious. Noninfectious skin disorders common in diabetes are pruritis, necrobiosis lipoidica, scleredema adultorum of Buschke, and granuloma annulare (Dryden 2015).
In addition to PVD, hyperglycemia causes interruption of blood microcirculation which leads to diabetic foot syndrome as well as other skin problems. Microvascular disorders associated with diabetes, like neuropathy, must be noticed and treated early to prevent complications in the skin. A technique that may be used as a preventative measure is diffuse reflectance spectroscopy (DRS) which can provide information about the physiological and morphological state of tissues. DRS has been implemented to assess the peripheral blood flow and oxygen saturation. Hyperspectral imaging (HIS) is a modern implementation of the DRS method providing information about the tissue functional state. It consists of a series of images of the object under study registered in narrow wavelength ranges. Analysis of the data allows us to assess the content of the main absorbers in the biological tissue, blood volume, oxygen saturations, etc. It is most commonly used to analyze the development of wounds, including diabetic ulcers, burns and bruises. It’s place in diabetes care would be to identify ulcers that are at risk of not healing so that they do not progress to become infected and the proper care can be taken (Dremin 2021). This HIS technology is widely used in other fields in the United States such as agriculture, environmental monitoring, and food processing but use in the medical field is not as popular. HIS technology could be a very important step in preventing diabetic skin complications.
The current American Diabetes Association diabetes treatment guidelines recommend that all adults with diabetes undergo a comprehensive foot evaluation at least annually. In diabetic patients with peripheral neuropathy, a thorough assessment should be done to determine if neuropathy alters kinesthetic or proprioceptive sensation during physical activity. If the neuropathy alters sensation during physical activity, the patient may be restricted to non-weight-bearing activities in order to minimize the risk of foot ulcers. All patients with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early so prompt treatment may be initiated (American Diabetes Association, 2021).
Diabetes care. American Diabetes Association. https://diabetesjournals.org/care/issue/44/Supplement_1. Published January 1, 2021. Accessed March 10, 2022.
Dryden M, Baguneid M, Eckmann C, et al. Pathophysiology and burden of infection in patients with diabetes mellitus and peripheral vascular disease: Focus on skin and soft-tissue infections. Clinical Microbiology and Infection. 2015;21. doi:10.1016/j.cmi.2015.03.024
V. Dremin et al., "Skin Complications of Diabetes Mellitus Revealed by Polarized Hyperspectral Imaging and Machine Learning," in IEEE Transactions on Medical Imaging, vol. 40, no. 4, pp. 1207-1216, April 2021, doi: 10.1109/TMI.2021.3049591.
Skin care in Diabetes
Diabetes can have many complications on the skin and self-care can be very helpful in combating or preventing these complications. Patients with diabetes are at an increased risk of infection due to the decrease in blood circulation usually in the lower limbs. This decrease in blood circulation tends to increase healing time of cuts and wounds which increases the risk for infections. Therefore, patients with diabetes must take extra precautions when taking care of their skin.
There are also warning signs that can appear on the skin that can be brought up to a medical professional. Some of the signs of skin complications are patches on the skin, dark spots on the skin, hard and thick skin, blisters, skin infections, sores, wounds, spots on the shins, outbreak of bumps, discoloration, dry and itchy skin, and skin tags. These signs can be signs of underlying issues and skin complications associated with diabetes.
Patients with diabetes should focus more on skin care than the average person because their skin is easily irritated and heals slower. There are many dermatologist-recommended skin care tips for patients with diabetes. These tips will help preventing and treating uncomfortable changes to your skin. One tip is the importance of moisturizing the skin every day. Keeping skin moisturized would help with flexibility and prevent cracking which can lead to an infection. It is also recommended to use creams and ointments over lotions because they can do a better job healing dry skin than lotions do. Creams or ointments that contain ceramides are also preferred. The best time to apply cream or ointment is after bathing, swimming, and when the skin feels dry or itchy. Another tip is to treat dry and cracked heels. This cracking of skin can lead to serious infection and non-healing sores. Using a cream that contains 10% to 20% urea every night before bed will help heal this skin.
It is also important to use gentle cleansers when showering and this will help prevent drying the skin. They also have many options specially formulated for patients with diabetes. It is also better to avoid showering with hot water because it can strip the skin of moisture. After showering, it is also important to dry the skin well with a towel so there is no leftover water which can lead to infection.
Calluses on the feet also may not seems serious but they should be taken care of by a doctor. These can lead to infections like cellulitis if not taken care of properly. Seeking immediate medical attention for skin and nail infection is best to avoid serious infections. Paying close attention to cuts, scratches, and wounds immediately is also extremely important to help heal them faster and avoid infections.
1. “Dermatologist-Recommended Skin Care for People with Diabetes.” American Academy of Dermatology, https://www.aad.org/public/diseases/a-z/diabetes-skin-care.
2. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord. 2013;12(1):14. Published 2013 Mar 5. doi:10.1186/2251-6581-12-14
Treatment for Diabetes
There are a wide variety of treatment options available for patients with diabetes. The treatment approach is determined based on the type of diabetes the patient has and other factors such as drug allergies, ineffectiveness of a drug, etc. Some of the treatment options considered are insulin (short-acting, rapid-acting intermediate-acting, long-acting, and combinations), amylinomimetics, alpha-glucosidase inhibitors, biguanides, dopamine agonists, dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, meglitinides, sodium-glucose transporter 2 inhibitors, sulfonylureas, and thiazolidinediones. There are so many of these treatment options, but some are preferred over others according to treatment guidelines.
In the pharmacologic therapy for adults with type 1 diabetes, most patients should be treated with multiple daily injections or prandial and basal insulin, or a continuous subcutaneous insulin infusion. Another recommendation is that most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk. It can also be helpful for patients to receive education on how to match mealtime insulin doses to carbohydrate intake, fat and protein content, and anticipated physical activity. This can help patient avoid hypoglycemia and dose their insulin better. Insulin treatment is pretty much essential for patients with type 1 diabetes and is the preferred option for type 1 diabetes. There are other options that have been studied such as pramlintide, metformin, GLP1 receptor agonists, and SGLT2 inhibitors. Only pramlintide is currently approved out of these for type 1 diabetes.
Treatment for type 2 diabetes has many more options and is more complicated than treating type 1 diabetes. The first line therapy for type 2 diabetes is usually metformin along with lifestyle modifications. This also depends on comorbidities, patient-centered treatment factors, and management needs. GLP-1 agonists and SGLT2 inhibitors with or without metformin are also considered to be proper initial treatment options for patients with type 2 diabetes with or at high risk for cardiovascular disease, heart failure, and/or chronic kidney disease. Insulin therapy can be considered for the treatment if the first options aren’t as effective, and metformin should be continued upon initiation of insulin. Early insulin initiation should be considered when A1C levels are >10% or with blood glucose levels above 300mg/dL. Some other factors that should also be considered when choosing treatment options are the effects on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost and availability, side effects, and patient preferences. These factors can add many barriers in picking the proper treatment options for patients. For example, if the patient has a phobia of needles, it will be difficult to have them inject insulin daily. In patients with cardiovascular disease or indicators for high cardiovascular risk, there have been benefits of using SGLT2 inhibitors and/or GLP-1 agonists. If possible, GLP-1 agonists are also preferred to using insulin in patients with type 2 diabetes. They can also be used together and would have greater efficacy and durability of the treatment effect. Intensifying treatment should not be delayed if patients aren’t meeting their treatment goals.
These are the basic treatment options for outpatient type 1 and type 2 diabetes management. There are many options, but there are a few that are preferred and seen in treatment more often.
1. American Diabetes Association Professional Practice Committee; 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2022. Diabetes Care 1 January 2022; 45 (Supplement_1): S125–S143.
2. Cherney, Kristeen. “List of Common Diabetes Medications.” Healthline, Healthline Media, 17 June 2020, https://www.healthline.com/health/diabetes/medications-list#other-drugs.
Testing for Diabetes
Diabetes can be diagnosed based on fasting plasma glucose value, 2 hour plasma glucose value during a 75g oral glucose tolerance test, or A1C levels. These same tests can help with detecting patients with prediabetes as well. Obtaining a fasting plasma glucose value can be done using a fingerstick and this test can be performed by a patient or healthcare professional. This is where a needle is used to puncture the skin at the tip of the finger, then a test strip absorbs the blood and is inserted into a reader that will detect the blood glucose level. The fasting plasma glucose is the value obtained where the patient hasn’t had any caloric intake for at least 8 hours. Obtaining the 2 hour plasma glucose value during a 75 g glucose tolerance test is the same process except the patient usually ingest 75g of glucose 2 hours before the fingerstick test is performed. The hemoglobin A1C test is a simple blood test that measures average blood sugar levels. This is usually done every three months for the most accurate readings. It can indicate if a patient’s blood sugar is well controlled or not. This test is done at the doctor’s office. There are recommendations around A1C values by the diabetes treatment guidelines. Some of these recommendations are that to avoid misdiagnosis or missed diagnosis, the A1C test should be performed using a method certified by NGSP and standardized to the Diabetes Control and Complications Trial assay. Also, If there is discordance between A1C and plasma glucose levels, there is a possibility of interference. Also, some factors that affect the blood such as sickle cell disease, G6PD deficiency, HIV, hemodialysis, transfusions, erythropoietin therapy, or pregnancy should be taken into consideration as well. In these cases, only plasma blood glucose criteria should be used to diagnose diabetes.
The criteria for diagnosing diabetes have set values for these tests. If a patient has a fasting plasma glucose of greater than 125 mg/dL OR a 2 hour plasma glucose greater than 200 mg/dL OR A1C greater than 6.5% OR if a patient with classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose of greater than 200, then these patients can be diagnosed with diabetes.
There are also criteria for who should be tested for diabetes or prediabetes in asymptomatic adults. Testing should be considered in adults who are overweight or obese. Other factors that call for testing are first-degree relatives with diabetes, high risk race/ethnicity, history of CVD, hypertension, out of range HDL or LDL, and physical inactivity. Patients with prediabetes should also be tested yearly. Women diagnosed with GDM should have lifelong testing at least every three years. For all patients, testing should begin at age 45. HIV patients should also be tested.
Diabetes is a very prevalent health condition and understanding how testing and diagnosis criteria is important. It helps to understand the disease better and assess treatment options better as well. There are some of the basic tests and criteria for diabetes used to diagnose diabetes.
1. Introduction: Standards of Medical Care in Diabetes—2021. Diabetes Care 1 January 2021; 44 (Supplement_1): S1–S2.
2. “Diabetes: Types, Risk Factors, Symptoms, Tests, Treatments & Prevention.” Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/7104-diabetes-mellitus-an-overview.
Diabetes is a chronic health condition that affects how the body releases and uses insulin. Most food is broken down into glucose and is released into our bloodstreams. When our blood sugar increases, it signals the pancreas to release insulin to regulate this glucose in the blood. The body either doesn’t produce enough insulin or has trouble utilizing the insulin produced as well as it should. Without this function, it can lead to an excess of glucose in the bloodstream, and this can cause other health complications such as heart disease and kidney disease. There is currently no cure for diabetes, but there are many diet and lifestyle changes that can help keep the blood glucose under control.
There are three types of diabetes, type 1, type 2 and gestational diabetes. Type 1 diabetes is caused by an autoimmune reaction that stops the body from producing insulin. Only 5-10% of patients with diabetes have type 1. This is usually diagnosed in children, teens, or young adults. This requires taking insulin every day. The second is type 2 diabetes where the body doesn’t use insulin well and can’t keep blood sugar at normal levels. This is the type majority of diabetes patients have. This is usually diagnosed in adulthood. This type can be prevented or delayed with healthy lifestyle changes. The third type is gestational diabetes which develops in pregnant women who never had diabetes. Gestational diabetes usually goes away after the birth of the baby but can increase the risk for type 2 diabetes later in life.
In the United States, more than 1 in 3 adults have prediabetes. This is where blood sugar levels are high, but they aren’t high enough for a type 2 diabetes diagnosis. Diabetes is the seventh leading cause of death in the United States. It is also the number one cause of kidney failure, lower-limb amputations, and adult blindness. In the past 20 years, the number of adults with diabetes has more than doubled.
Diabetes also comes with many skin complications as well. It can have effects on the skin that requires self-care or medical attention. Diabetes can contribute to bacterial infections, fungal infections and itching. Patients with diabetes are at an increased risk for styes, boils, folliculitis, carbuncles, and infections around the nails. With proper medical attention, these can be taken care of and will most likely not lead to death. Another issue is fungal infections and most people with diabetes have fungal infections caused by Candida Albicans. These infections occur in warm, moist folds of the skin. This can affect anyone, but patients with diabetes are at a higher risk. Poor blood circulation caused by diabetes also can contribute to itching, so patients might experience itching around the body and mostly in the lower parts of the legs.
There are many preventative measures that can be taken to prevent skin problems. These measures are keeping diabetes under control, keep skin clean and dry, avoid hot baths and showers, prevent dry skin, treat cuts right away, using mild shampoos, staying in a humid environment, and taking proper foot care precautions. These are some of the best ways to prevent the skin issues caused by diabetes.
1. “Diabetes and Skin Complications.” Diabetes and Skin Complications | ADA, https://www.diabetes.org/diabetes/skin-complications.
2. “What Is Diabetes?” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 16 Dec. 2021, https://www.cdc.gov/diabetes/basics/diabetes.html.