Pattern of dermatoses in diabetics

Introduction

The association of certain skin diseases with diabetes mellitus has been fairly well recognized with an incidence rate ranging from 1 1.4%[1] to 66%[2]. Urbach[3] showed that skin sugar levels run parallel to the blood sugar levels. Krall and zorilla[4] were able to identify diabetes by mere inspection of the skin and noting increased frequency of skin spots and red facies. Others[1],[5],[6] reported increased incidence of various types of bacterial and fungal infections in the diabetics and correlated it with the increased concentration of glucose in the skin which acted as a substrate for the growth of these organisms. Pastras and Beerman[7] observed that without control of diabetes there is little or no response to therapy in some of these cutaneous processes.

Materials and Methods

Two hundred diabetic patients attending the diabetic clinic, medical out-patient department and skin out-patient department and different wards of pt. J.N.M. Medical College Hospital, Raipur, were studied. A detailed history and clinical examination, especially for the presence of cutaneous lesions, was carried out in proper sun light. Fundus and routine blood, stool and urine examinations were carried out in all the patients. Blood sugar estimation was done by alkaline copper reduction method.[8] Scrapping and direct KOH examination and culture for fungus in sabouraud′s agar and gram staining and culture of the pus was done to identify the type of bacterial organism in selected cases. Histopathological examination of the skin sections was carried out wherever necessary to confirm the diagnosis.

Results

Among the 200 patients of diabetes mellitus, there were 125 (62.5%) males and 75 (37.5%) females. The age of the patients ranged from 20 years to 80 years (mean 61.4+12.8 years). A total of 122 (61 %) patients had some associated cutaneous diseases comprising 65 (53.3%) males and 57 (46.7%) females. The associated dermatoses were equally prevalent in all the age groups. Female diabetic patients had a significantly (t=4.66, p 40.05) high incidence of associated skin diseases as compared to male diabetics.

Among 122 diabetics with dermatoses, 101 (82.1 %) cases were of maturity onset type of diabetes mellitus (MODM) while 21 (17.9%) cases were of juvenile type (JODM). The duration of diabetes ranged from 2 months to 27 years (mean 66.46+58.84 months). The mean fasting blood sugar level was 157.24 + 62.13 mg per 100 ml while the mean post prandial blood sugar level was 247.36+101.68 mg per 100 ml. There was no significant difference in the blood sugar levels in both diabetics with dermatoses and diabetic cases without dermatoses. 58.5% cases had their fundus within normal limits while a background diabetic retinopathy was present in 27.5% of cases.

The sex-wise distribution of various dermatoses observed in diabetic patients is shown in [Table - 1]. The bacterial and fungal infections of the skin formed the largest clinical entities with 32 cases and 21 cases respectively followed by skin tags (11 cases). The frequency distribution of various types of bacterial infections of the skin in diabetics is shown in [Table - 2]. Staphylococcus aureus was the most frequently isolated organism in these lesions [Table - 3]. Among the fungal infections tinea cruris was present in 7 cases followed by tinea corporis and tinea unguium in 3 cases each. Trichophyton rubrum was the most frequently isolated agent, present in 1 1 cases. Monilial infection was seen in 9 cases. Pruritus was present in 9 (4.5%) cases only.

Discussion

Some form of cutaneous involvement was present in 61 % of the diabetic patients confirming that cutaneous lesions are frequent and common in diabetics. Haneef[9] and Chhabra[2] also observed a high incidence rate of 55.7% and 66% respectively of skin lesions in diabetic patients. Bedi and Kandhari,[10] however, observed a slightly lower incidence rate of 42.5% of cases with cutaneous involvement among the diabetic patients. In present study, female diabetic patients had a significantly high (p=0.05) incidence of cutaneous diseases as compared to male diabetics. Binkley[11] and Danowsky et al,[12] whereas observed a higher incidence of cutaneous diseases among male diabetics. The skin diseases were equally prevalent in all the age groups among the diabetic patients and the incidence rate was 48%, 51% and 50.6% in the 5th, 6th and 7th decade of life respectively whereas Chhabra[2] in his study observed 33.3% 23.5% and 9.9% incidence of skin diseases in 5th, 6th and 7th decades of age. The relative increase in the incidence of cutaneous diseases with age in our patients may be because of decreased resistance of body as well as long duration of diabetes. The prevalence of skin diseases was similar in both patients with maturity onset diabetes mellitus and juvenile onset type of diabetes mellitus. The diabetic status was uncontrolled in 104 (52%) cases out of all the 200 cases of diabetes. The incidence of cutaneous diseases in patients with uncontrolled diabetes mellitus was 70.2% while only 51% patients with controlled diabetes, and fungal agents formed largest group of cutaneous lesions and it may be because most of our patients belonged to lower socio economic group residing in slum areas where hot and humid conditions, overcrowding and decreased resistance of the body predisposes the individuals for such infections. Associated diabetic retinopathy was present in 32.8% of cases of diabetics with cutaneous diseases while it was seen in only 24.3% cases of diabetes without cutaneous disorders. Binkley[11] also reported a high frequency of skin diseases in diabetic retinopathy along with skin diseases in 33.3% of cases. Retinopathy usually occurs late in diabetes mellitus but may occur at an early age specially in patients with uncontrolled diabetes. Hence, it appears that prolonged uncontrolled diabetes mellitus triggers not only the involvement of other target organs but also predisposes skin for various infections and other cutaneous diseases.