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ORIGINAL CONTRIBUTIONS
Year : 1990  |  Volume : 56  |  Issue : 1  |  Page : 18-21

Clinical study of diabetic dermoangiopathy




Correspondence Address:
MPS Sawhney


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  Abstract 

One hundred and twenty three diabetic patients and 100 non- diabetic controls were examined for lesions of diabetic dermoangiopathy. Twenty two (17.9%) lesions, while simildr lesions were found in only 2 (2%) controls. Age of the patients with opathy was sipifirandy higher than those derm without dermopathy, and it was more common in the fifth to the seventh decade. No statistically siicant relationship could be established with the sex, type, serverity control or duration of diabetes, diatetic neuropathy, larize vessel disease like CAD, PVD or CVA or with metabolic complications of diabetes. However, a higher percentage (59.1%) of patients with dermopathy were found to have a poor control of their diabetes as compared to those without microangiopathy (50.7%). Dermopathy was also more common (23%) 9 the duration of diabetes was more than 5 years, than if it was less than 5 years (14.1%). The percentage (33.3% of patients with retinopathy having dermopathy. Rubeosis was seen in 4 (3.2%) patients.


Keywords: Diabetic dermoangiopathy, Dermopathy


How to cite this article:
Sawhney M, Tutakne M A, Rajpathak S D, Tiwari V D. Clinical study of diabetic dermoangiopathy. Indian J Dermatol Venereol Leprol 1990;56:18-21

How to cite this URL:
Sawhney M, Tutakne M A, Rajpathak S D, Tiwari V D. Clinical study of diabetic dermoangiopathy. Indian J Dermatol Venereol Leprol [serial online] 1990 [cited 2019 Jun 19];56:18-21. Available from: http://www.ijdvl.com/text.asp?1990/56/1/18/3471


Diabetes mellitus is the most common of the serious metabolic disorders in the man. Its frequency in the general population is between 2 to 6%. Better understanding of the disease and improvement in the therapeutic modalities have reduced the life threatening metabolic complica­tions of diabetes. With this, vascular complica­tions have emerged as the leading cause of morbidity and mortality amongst the diabetics, and have consequently received considerable attention. Disease of blood vessels as a conse­quence of diabetic angiopathy does not obey any anatomical or physiological boundary. It affects the largest arteries (macroangiopathy) causing coronary artery disease (CAD), cere­brovascular accident (CVA) and peripheral vascular disease (PVD), to the smallest capi­llaries (microangiopathy) causing retinopathy, neuropathy, nephropathy and dermoangiopathy.

Interest in the skin manifestations of diabetic microangiopathy started in 1964 when Bauer et al[4] demonstrated periodic acid-Schiff (PAS) positive capillary basement membrane thick­ening (CBMT) in necrobiosis lipoidica diabe­ticorum (NLD) which was similar to the changes seen in diabetic microangiopathy in dermo­pathic lesions by Binkley[2] and in granuloma annulare (GA).[3] Kurwa et all suggested that bullosis diabeticorum may also be caused by diabetic microangiopathy. Rubeosis charac­terised by rosy coloration of the cheeks may be another manifestation of microangiopathy.[5],[6]

In this study, the incidence of various skin manifestations of diabetic microangiopathy and correlation of diabetic dermopathy with the severity, duration, control and other complica­tions of diabetes as well as with retinal micro­angiopathy in diabetic patients was undertaken.


  Materials and Methods Top


One hundred and twenty three diabetic patients under treatment in the diabetic clinic and 100 age and sex matched non-diabetic controls were included in this study. Detailed history and examination, with special emphasis on examination of the skin, were done. Persons with varicose veins and those with a family history of diabetes were excluded from the controls. Routine blood, urine, blood urea, serum creatinine, serum cholesterol, skiagram of the chest and fasting and post-prandial blood sugar were done in all the diabetics. Fundoscopy could be done in 85 diabetics. Other investiga­tions like ECG, urine culture, sputum for AFB etc were done in cases suspected to have compli­cations of diabetes. Blood sugar levels were also done in all the controls. Dermatological examina­tion was done to look for the lesions of diabetic microangiopathy, especially diabetic dermo­pathy,[5] necrobiosis lipoidica diabeticorum (NLD),[6] bullosis diabeticorum,[5] granuloma amiulare (GA),[7] and rubeosis, 5 and also to look for skin infections. In addition, blood sugar levels during the last 1-12 years were recorded to find out the status of control of diabetes. The criteria for the assessment of the control of diabetes into good, satisfactory and poor were those as followed by the Joslin clinic,[8] and for the severity of diabetes into mild, moderately severe and severe diabetes were based on the criteria used by Bellet and Roman.[9] Assessment of the diabetic retinopathy was done by an ophthalmologist by fundus examination, and of diabetic nermopathy , by clinical examination. Chi square test was used as a test of significance.


  Results Top


There were 57 male and 66 female diabetic patients with an age range of 14-80 years and the mean age of 50.2-14.9 years. Similarly, 100 controls comprised of 54 males and 46 females with an age range of 15-78 years and the mean age of 47.5±18.4 years. Hyperpigmented atrophic patches of diabetic dermopathy were seen in 22 (17.9%) diabetic patients as compared to 2 (2%) controls, a statistically significant difference (p<0-05). Rubeosis was seen in four (3.2%) patients and in none of the controls. All cases of rubeosis were females, of fair skin colour and with lesions on the face. No patient had NLD, granuloma annulare or bullosis diabeticorum.

Of the 22 patients with diabetic dermopathy, 10 (17.5% of males) were males and 12 (18.2% of females) were females. [Table - 1] gives the age distribution of the patients with and without dermopathy.

The mean age of patients with dermopathy was 55.4 + 11.9 years (range 35-80 years) and of those without it was 49 + 15.2 years (range 14-78 years), a statistically significant difference (p<0.05). The site of de mopathic lesions was the front of legs in 21 cases, extensor surface of forearms in 7, dorsum of the feet in 2, and the lower part of thighs and neck in one patient each. The number of lesions varied from 1-20.

Five (14.7%) of the 34 patients with insulin dependent diabetes mellitus (IDDM) had dermopathy as compared to 17 (19.3%) of 88 patients having non-insulin dependent diabetes mellitus (NFDDM). One patient with secondary diabetes did not have dermopathy. The difference was not significant.

Ten (14.1 %) of 71 patients with the duration of diabetes less than 5 years, 7 (22.5%) of 31 patients with the duration 5-10 years and 5 (23.8%) of 21 patients with the duration more than 10 years had lesions of dermopathy.

Eighteen (20.2%) of 89 patients with mild, none of the 8 patients with moderately severe, and 4 (15.4%) of 26 patients with severe diabetes had lesions of dermopathy. Similarly, 3 (15%) of 20 cases with good, 6 (15.4%) of 39 cases with satisfactory and 13 (20.3 %) of 64 cases with poor control of their diabetic state had lesions of dermopathy.

Fundoscopy could be done in 85 cases only. Four (33.3%) out of 12 cases of retinopathy also had dermopathy, while only 10(13.7%) out of 73 patients without retinopathy had dermopathy. Seven (17.94%) of 39 patients with and 15 (17.85%) of 84 patients without neuro­pathy also had dermopathic lesions.

[Table - 2] depicts the association of diabetic dermopathy with the other complications of diabetes.


  Comments Top


Dermopathic lesions were found in 1.5% of the normal students[10] compared to 2% in our controls. Male to female ratio was almost equal in our study, though others[2],[10] had shown a higher incidence among the males. The overall incidence has been reported to be 50%[10] compared to 17.8%, in our study. The Indian skin being dark, it may be difficult to appreciate a few isolated lesions, which are asymptomatic.

All our cases of dermopathy were above the age of 40 years except one case who was 35-year-old, as also reported by others.[2],[11] Mean age(±SD) of the patients with dermopa­thy was higher (55.4 + 11.9 years) as compared to the patients without dermopathy (49±15.2 years), indicating that dermopathy tends to occur in the older age group. Dermopathy was more common (23%) if the duration of diabetes was more than five years than if it was less than 5 years (14.1 %). Fisher and Danowski[12] had found no correlation between the dermopathy and the duration of the disease, while Danowski et al[10] reported increased frequency with increased duration of the disease. There was no correlation between the dermopathy and the type, the severity and the control of diabetes, as has been reported by others.[2],[13]

Retinopathy was more common (33.3%) in patients with dermopathy as compared to those without it (13.7% % ), but this difference was statistically not significant because of the small number of cases. Binkley[2] and Boyd et all[11] also found more common association between the two, as opposed to Danowski et al[10] who had found none. Dermopathy was found as commonly (17.9%) inpatients with neuropathy, as in the patients without (17.85%) and this is in contradiction to the findings of others.[2],[10],[11]

There was no correlation between the dermo­pathy and the macrovascular diseases like CAD, PVD and CVA, though hypertension was more common (22.7%) in cases with dermopathy than without it (8.9%), but the difference was statistically not significant. Parving 14sub hypothesized that hypertension may accelerate the process of microangiopathy.

Skin infections-bacterial, fungal and candi­dial were more common (22.7%) in cases with dermopathy as compared to those without it (12.8%).

Front of the legs was the most common (95.4%) site of dermopathy.[2],[10],[12] Other sites were extensor surface of the forearms (31.8%), dorsum of feet (9%), lower part of thighs (4.5%) and neck (4.5%). Cases with generalised lesions involving the thighs, abdomen, under the breast and arms have been described,[15] as was also seen in three of our cases.

The incidence of rubeosis in diabetics reported in the western literature is much higher (50%)[6] as compared to only 3.20 seen in our cases. This is because it is less well appreciated in the dark skin.[5]

 
  References Top

1.Bauer MF, Hirsch P, Bullock WK et al : Necro­hiosis lipoidica diabeticorum. A cutaneous mani­festation of diabetic microangiopathy, Arch Dermatol, 1964; 90 : 558-566.  Back to cited text no. 1    
2.Bnkley GW : Dermopathy in diabetic syndrome, Arch Dermatol, 1965; 92 : 625-634.  Back to cited text no. 2    
3.Rhodes FL, Hill DM, Ames AC et al : Granuloma annulare. Prednisolone glycosuria test in non­ diabetic group, Brit J Dermatol, 1966; 78 : 532-535.  Back to cited text no. 3    
4.Kurwa A, Roberts P and Whitehead R : Con­currence of bullous and atrophic skin lesions in diabetes mellitus, Arch Dermatol, 1971; 103 670-675.  Back to cited text no. 4    
5.Fine JD and Moschella SL : Diseases of nutrition and metabolism, in : Dermatology, 2nd ed, Editors, Moschella SL and Hurley HJ : WB Saunders, Philadelphia, 1985; p 1497-1501.  Back to cited text no. 5    
6.Gilgor RS and Lazarus GS : Skin manifestations of diabetes mellitus, in : Diabetes Mellitus Therapy and Practice, 3rd ed, Editors, Ellenberg M and Rafkin H : Medical Examination Publications, New York, 1983; p 879-893.  Back to cited text no. 6    
7.Alexander S : Skin disorders associated with diabetes, in : Complications of Diabetes, 2nd ed, Editors, Keen H and Jarret J : Edward Arnold, London, 1982; p 205-213.  Back to cited text no. 7    
8.UGDP Study : Effect of hypoglycaemic agents on vascular complications in patients with adult onset diabetes. VIII, Evaluation of insulin therapy Final Report, Diabetes, 1982; 31 (Supp15) : 1-81.  Back to cited text no. 8    
9.Bellet S and Roman L : The exercise test in diabetic patients as studied by radio-electrocardiography, Circulation, 1967; 36 : 245-254.  Back to cited text no. 9    
10.Danowski TS, Sabeh G, Sarver ME et al : Skin spots and diabetes mellitus, Amer J Med Sci, 1966: 251 : 570-575.  Back to cited text no. 10    
11.Boyd SG, Innes SM and Campbell 1W : Shin manifestations of diabetes mellitus, Practitioner, 1982; 226 : 253-264.  Back to cited text no. 11    
12.Fisher ER and Danowski TS : Histological, histochemical and electronmicroscopic features of the skin spots of diabetes mellitus, Amer J Clin Pathol, 1968; 50 : 547554.  Back to cited text no. 12    
13.Oyer DS : Diabetes mellitus. New developments, Arch Dermatol, 1982; 118 : 132-134.  Back to cited text no. 13    
14.Parving HH : Increased microvascular perme­ability to plasma proteins in short and long term juvenile diabetes, Diabetes, 1976; 25 (Suppl- 2) 884.  Back to cited text no. 14    
15.Bauer M and Levan NE : Diabetic dermoangio­pathy. A spectrum including pigmented pretibial patches and necrobiosis lipoidica diabeticorum, Brit J' Dermatol, 1970; 83 : 528-535.  Back to cited text no. 15    


    Tables

[Table - 1], [Table - 2]

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