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The Prevalence of Cutaneous Manifestations in Young Patients with Type 1 Diabetes

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The Prevalence of Cutaneous Manifestations in Young Patients with Type 1 Diabetes Clinical Care/Education/Nutrition/Psychosocial Research ORIGINAL ARTICLE The Prevalence of Cutaneous Manifestations in Young Patients With Type 1 Diabetes 1 2 MILOSˇ D. PAVLOVIC´, MD, PHD SLAANA TODOROVIC´, MD tions, such as neuropathic foot ulcers; 2 4 TATJANA MILENKOVIC´, MD ZORANA ÐAKOVIC´, MD and 4) skin reactions to diabetes treat- 1 1 MIROSLAV DINIC´, MD RADOSˇ D. ZECEVIˇ , MD, PHD ment (1). 1 5 MILAN MISOVIˇ C´, MD RADOJE DODER, MD, PHD 3 To understand the development of DRAGANA DAKOVIC´, DS skin lesions and their relationship to dia- betes complications, a useful approach would be a long-term follow-up of type 1 OBJECTIVE — The aim of the study was to assess the prevalence of cutaneous disorders and diabetic patients and/or surveys of cuta- their relation to disease duration, metabolic control, and microvascular complications in chil- neous disorders in younger type 1 dia- dren and adolescents with type 1 diabetes. betic subjects. Available data suggest that skin dryness and scleroderma-like RESEARCH DESIGN AND METHODS — The presence and frequency of skin mani- festations were examined and compared in 212 unselected type 1 diabetic patients (aged 2–22 changes of the hand represent the most years, diabetes duration 1–15 years) and 196 healthy sex- and age-matched control subjects. common cutaneous manifestations of Logistic regression was used to analyze the relation of cutaneous disorders with diabetes dura- type 1 diabetes seen in up to 49% of the tion, glycemic control, and microvascular complications. patients (3). They are interrelated and also related to diabetes duration. Timing RESULTS — One hundred forty-two (68%) type 1 diabetic patients had at least one cutaneous of appearance of various cutaneous le- disorder vs. 52 (26.5%) control subjects (P Ͻ 0.01). Diabetes-associated skin lesions were found sions in young patients with diabetes in 81 (38%) patients. Acquired ichthyosis, rubeosis faciei, diabetic hand, and necrobiosis li- might be potentially useful for the research poidica were seen in 22 vs. 3%, 7.1 vs. 0%, 2.3 vs. 0%, and 2.3 vs. 0% of type 1 diabetic and of their pathogenesis (i.e., derangement of control subjects, respectively. The frequency of cutaneous reactions to insulin therapy was low epidermal lipid metabolism), therapeutic (–2.7%). The prevalence of fungal infections in patients and control subjects was 4.7% and 1.5%, respectively. Keratosis pilaris affected 12% of our patients vs. 1.5% of control subjects. Diabetic intervention (i.e., application of moisturiz- hand was strongly (odds ratio 1.42 [95% CI 1.11–1.81]; P Ͻ 0.001), and rubeosis faciei weakly ers or antifibrosing agents), or predicting (1.22 [1.04–1.43]; P ϭ 0.0087), associated with diabetes duration. Significant association was microvascular complications. We decided also found between acquired ichthyosis and keratosis pilaris (1.53 [1.09–1.79]; P Ͻ 0.001). to examine an unselected young type 1 di- abetic population to see what kind of cuta- CONCLUSIONS — Cutaneous manifestations are common in type 1 diabetic patients, and neous manifestations develop at an earlier some of them, like acquired ichthyosis and keratosis pilaris, develop early in the course of the age and with a shorter duration of diabetes. disease. Diabetic hand and rubeosis faciei are related to disease duration. Diabetes Care 30:1964–1967, 2007 RESEARCH DESIGN AND METHODS — Two hundred and twelve children, adolescents, and young hough it is well known that diabe- first presenting sign or even precede the adults with type 1 diabetes (113 male and tes is associated with a number of diagnosis by many years. The cutaneous 99 female subjects), with disease onset at cutaneous manifestations (1–3), findings can be classified into four ma- T age Յ15 years (Table 1) and consecu- there is a relative paucity of studies jor groups: 1) skin diseases associated tively attending the outpatient diabetes looking at the prevalence of skin with diabetes, such as scleroderma-like clinic at the Mother and Child Healthcare changes in young patients with type 1 changes of the hand, necrobiosis li- Institute of Serbia over a 5-month period diabetes. Cutaneous manifestations poidica, and diabetic dermopathy; 2) (April through August 2005), were exam- generally appear subsequent to the de- cutaneous infections; 3) cutaneous ined by two dermatologists. They took a velopment of diabetes but may be the manifestations of diabetes complica- medical history about skin diseases and ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● performed the whole-body cutaneous ex- amination, including visible mucosal sur- From the 1Department of Dermatology, Military Medical Academy, Belgrade, Serbia; the 2Department of Endocrinology, Mother and Child Healthcare Institute of Serbia “Vukan E` upic´,” Belgrade, Serbia; the 3De- faces. During the same time frame, 196 partment of Dental Medicine, Military Medical Academy, Belgrade, Serbia; the 4Institute of Dermatovene- healthy children and adolescents (115 reology, Clinical Center of Serbia, Belgrade, Serbia; and the 5Department of Gastroenterology, Military male and 81 female subjects, aged 3–21 Medical Academy, Belgrade, Serbia. years, mean 11.5 Ϯ 4.2) attending the Address correspondence and reprint requests to Dr. Milosˇ D. Pavlovic´, Dermatology, Military Medical Academy, Crnotravska 17, 11002, Belgrade, Serbia. E-mail: [email protected]. dental medicine service of the Military Received for publication 8 February 2007 and accepted in revised form 12 May 2007. Medical Academy for a routine dental Published ahead of print at http://care.diabetesjournals.org on 22 May 2007. DOI: 10.2337/dc07-0267. check-up also underwent dermatological A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion examination by the same physicians. All factors for many substances. clinically definable cutaneous lesions © 2007 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby were recorded in both populations. marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Scleroderma-like skin changes of the 1964 DIABETES CARE, VOLUME 30, NUMBER 8, AUGUST 2007 Pavlovic´ and Associates Table 1—Characteristics of the study popu- Due to a well-known ␣-inflation associ- ence was highly significant (Table 2; P Ͻ lation of 212 young patients with type 1 dia- ated with stepwise logistic regression and 0.01). Thyroid-stimulating hormone lev- betes several regressions performed, a cutoff for els were normal in all patients with ich- significance level for variables in the thyosiform skin changes. Rubeosis, Յ Characteristics model was set at P 0.01. diabetic hand (scleroderma-like changes and/or limited joint mobility), and necro- Age (years) 12.5 Ϯ 3.7 (2–22) RESULTS — The clinical data of the biosis lipoidica were found only in pa- Sex (male/female) 113/99 study population are given in Table 1. A tients with type 1 diabetes (Table 2). All Duration of diabetes 4.2 Ϯ 3.0 (1–15) total of 142 patients (68%) had at least five subjects with diabetic hand were (years) one cutaneous disorder, and 81 patients boys, and two of them also had Du- Age at onset (years) 8.3 Ϯ 3.6 (0.5–15) (38%) had skin lesions considered to be puytren’s contracture. The prevalence of Diabetes complications associated with diabetes (Table 2). The necrobiosis lipoidica in our type 1 dia- Nephropathy 15 (7) most prevalent cutanous manifestation betic population was 2.3%. Though the Retinopathy 0 (0) was xerosis, found in 22% of type 1 dia- prevalence of fungal, viral, and bacterial Neuropathy 0 (0) betic patients. In control subjects, the ich- infections was higher in the study popu- Hypertension 4 (1.9) thyosiform changes affected only 3% of lation (4.3, 4.3, and 3.0%, respectively) Cumulative A1C 9.1 Ϯ 1.6 the children and adolescents. The differ- than in control subjects, the difference Data are means Ϯ SD (range) or n (%). Table 2—Distribution of cutaneous lesions in 212 young type 1 diabetic patients and 196 age- hand were diagnosed and assessed ac- and sex-matched control subjects cording to the criteria of Seibod (4). Xerosis (acquired ichthyosis) was clini- Patients Control subjects cally diagnosed based on the palpatory (n ϭ 212) (n ϭ 196) feeling of dry and rough skin accompa- Male/ Male/ nied by visible squames. The disorder was Lesions n (%) female n (%) female typically most severe over shins. In a few cases in which the diagnoses of the two Skin manifestations associated with diabetes examiners were discordant, they exam- Xerosis (acquired ichthyosis) 47 (22.2)* 24/23 6 (3) 3/3 ined the patient together with a third der- Diabetic hand 5 (2.3)† 5/0 0 (0) 0 matologist and reached a consensus. Rubeosis 15 (7.1) 6/9 0 (0) 0 Medical files were reviewed for data on Necrobiosis lipoidica 5 (2.3) 1/4 0 (0) 0 diabetes duration, A1C levels, fasting tri- Infections glycerides, cholesterol and thyroid- Fungal 10 (4.7) 3/7 3 (1.5)‡ 3/0 stimulating hormone levels, and renal Tinea pedis 4 (1.9) 2/2 1 (0.5) 1/0 function. Cumulative A1C values as a Onychomycosis 2 (0.9) 2/0 0 (0) 0/0 measure of glucose control were ex- Candidosis 4 (1.9) 1/3 0 (0) 0/0 pressed as a mean of the yearly A1C levels. Viral warts 8 (3.7) 4/4 4 (2) 2/2 Retinopathy was diagnosed by an experi- Bacterial 7 (3.3)§ 5/2 2 (1) 0/2 enced ophthalmologist using direct and in- Impetigo 3 (1.4) 1/2 1 (0.5) 0/1 direct ophthalomoscopy, nephropathy was Folliculitis 3 (1.4) 2/1 1 (0.5) 0/1 assessed by means of albumin excretion rate Skin reactions to insulin therapy using three consecutive timed overnight Lipohypertrophy 4 (1.8) 2/2 0 (0) 0/0 urine collections (albumin excretion rate Lipoatrophy 2 (0.9) 0/2 0 (0) 0/0 Ն20 ␮g/min in at least two of three mea- Other skin disorders surements), and peripheral neuropathy was Acne 41 (19.3) 20/23 31 (15.5) 17/14 assessed by means of a positive diabetic Keratosis pilaris 27 (11.7)* 13/14 3 (1.5) 3/0 neuropathy index (5) and, when indicated, Pityriasis versicolor 2 (0.8) 2/0 5 (2.5) 4/1 electromyoneurography.
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