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Impact of Glycaemic Control on the Pattern of Cutaneous Disorders in Diabetes Mellitus

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Impact of Glycaemic Control on the Pattern of Cutaneous Disorders in Diabetes Mellitus Review Article Clinician’s corner Images in Medicine Experimental Research Case Report Miscellaneous Letter to Editor DOI: 10.7860/JCDR/2019/36742.12604 Original Article Postgraduate Education Impact of Glycaemic Control on the Pattern Case Series of Cutaneous Disorders in Diabetes Mellitus- Dermatology Section A Hospital Based Case Control Study Short Communication BALASUBRAMANIYAN POORANA1, PULLABATLA VENKATA SIVA PRASAD2, PITCHAI KALIAPERUMAL KAVIARASAN3, SWAMINATHAN SELVAMUTHUKUMARAN4, KALYANASUNDARAM KANNAMBAL5 ABSTRACT non diabetic patients who attended our OPD, constituted the Introduction: The skin is the largest and the most visible organ of control group. They were subjected to relevant investigations. the body. It is a well known fact that it is referred to as window or Fasting blood sugar, post prandial blood sugar, glycosylated mirror to the internal health of the body. Abnormalities of insulin haemoglobin levels and renal function test were done for all and elevated blood glucose levels lead to metabolic, vascular, patients. Potassium hydroxide mount and gram stain were neurological and immunological abnormalities. Affected organs done for relevant cases. Chi-square test was used for statistical include the cardiovascular, renal, nervous system, eyes and the analysis using software SPSS version 21. skin. The skin manifestations can be the first presenting sign Results: The most common dermatological manifestation among of diabetes but more often appear in known diabetic patients diabetics was cutaneous infections, seen in 126 (42%) patients. during the course of the disease. Among the infections, fungal infections predominated in 89 Aim: To study the clinical profile of cutaneous lesions in diabetic (29.7%) patients, followed by bacterial infections in 31(10.3%) patients and to compare the pattern of these dermatoses with patients. There was a statistically significant correlation between HbA1C levels (glycosylated haemoglobin). infections and uncontrolled diabetes (HbA1C >7). Materials and Methods: Three hundred consecutive diabetic Conclusion: Skin is involved quite often in diabetics, some of patients with cutaneous manifestations who attended which can be a consequence or can be a clue for the diagnosis dermatology OPD at Rajah Muthiah Medical College, of underlying diabetes. Diabetic control is very important in Chidambaram from November 2013 to October 2015, reducing the morbidity and mortality of the diabetic patients. constituted the study group. Hundred age and sex matched Keywords: Dermatoses in diabetes, Diabetic bulla, Fungal infections INTRODUCTION is a teaching medical institution situated in a rural town catering to Diabetes mellitus, the most common endocrine disorder causes the needs of 4,69,416 population. A total number of 300 diabetic significant impairment of the various organ systems of the body patients with various dermatoses were enrolled as study group. including skin. The prevalence of dermatological disorders seen Sample size was not calculated. It was just fixed based on the in diabetic patients is around 32% [1]. Prolonged hyperglycaemia previous studies [4,5]. Hundred non diabetic patients with various results in production of advanced glycosylated end products which dermatoses, constituted the control group. All confirmed cases of in turn is responsible for most of the complications of diabetes. The diabetes with cutaneous manifestations irrespective of age, sex, pathogenic mechanisms like abnormal carbohydrate metabolism, associated diseases and those who were willing to participate in the atherosclerosis, microangiopathy, neuron degeneration and impaired study were included in the study group and all non diabetics with host mechanisms can be the causes of various dermatoses in cutaneous manifestations were taken as control group. diabetes [2]. Patients who did not give consent and gestational diabetes patients Cutaneous manifestations of diabetes mellitus usually appear were excluded from the study. The ethical clearance was sought subsequent to the development of the disease, but sometimes it from the institutional ethical committee before starting the study. may be the first presenting sign and in some cases they may even Informed consent has been obtained from all patients. All relevant precede the onset of primary disease by many years [3]. Therefore, details were entered in the case report form and associated early recognition of these manifestations will help to achieve good comorbid conditions were also noted. All patients underwent glycaemic control and prevent morbidities. Many similar studies a detailed dermatological examination. Various investigations had been conducted throughout the country [1,2]. Studies done by like fasting blood sugar, post prandial blood sugar, glycosylated Raghu TY et al., and Rao GS et al., showed infections as the major haemoglobin (HbA1C) levels, renal function test, lipid profile cutaneous manifestations among diabetics and fungal infections and urine analysis were done for all patients. Gram stain, KOH accounted for the majority of infections [1,2], but only very few mounts and skin biopsy were done in relevant cases to confirm studies exist from Tamil Nadu and Pondicherry [3]. This made us to the dermatological diagnosis. The classification of cutaneous conduct this study. The aim of this work is to analyse the pattern of manifestations in diabetes proposed by Sreedevi C had been various cutaneous lesions among diabetic patients and to compare adapted for this study [Table/Fig-1] [6]. it with HbA1C levels. STATISTICAL ANALYSIS MATERIALS AND METHODS Descriptive statistical analysis was done using software SPSS A prospective case control study was conducted at RMMCH for a version 21. Chi-square test was used for the comparison. Level of period of two years from November 2013 to October 2015. RMMCH significance was fixed as 5% (p-value <0.05). Journal of Clinical and Diagnostic Research. 2019 Feb, Vol-13(2): WC01-WC05 1 Balasubramaniyan Poorana et al., Impact of Glycaemic Control on the Pattern of Cutaneous Disorders in Diabetes Mellitus www.jcdr.net Serial Factor Study group (N-300) Control group (N-100) Classification Dermatoses No Age No % No % Diabetic bullae Necrobiosis lipoidica diabeticorum <20 yrs 1 0.33 0 0 Strongly associated but not Diabetic dermopathy 1 specific for diabetes (disease 21-30 yrs 4 1.33 5 5 Granuloma annulare markers) Scleroderma like syndrome 31-40 yrs 22 7.33 27 27 Pruritus 41-50 yrs 84 28.00 27 27 Diabetic foot Cutaneous infections 51-60 yrs 100 33.33 26 26 Xanthomatosis 2 Due to diabetic complications Xanthelasma 61-70 yrs 57 19.00 7 7 Phycomycetes >70 yrs 32 10.67 8 8 Malignant otitis media Sex Microangiopathy Due to neurovascular 3 Macroangiopathy Male 175 58.3 53 53.0 complications Diabetic neuropathy Female 125 41.7 47 47.0 With Oral hypoglycaemic drugs 4 Due to diabetes treatment With Insulin Duration of Diabetes Endocrine syndromes with <1 yrs 70 23.3 - - 5 Migratory necrolytic erythema diabetes mellitus 1-5 yrs 101 33.7 - - Psoriasis 6-10 yrs 52 17.3 - - Lichen planus Vitiligo >10 yrs 77 25.7 - - Commonly associated with Perforating dermatoses 6 diabetes mellitus Eruptive xanthomas Type of DM Bullous pemphigoid Type I 3 1.0 - - Dermatitis herpetiformis Kaposi sarcoma Type II 297 99.0 - - [Table/Fig-1]: Classification of cutaneous manifestations in diabetes [6]. Family History DM No 153 51.0 63 63.0 RESULTS Yes 147 49.0 37 37.0 The demographic details of the patients in both the groups are shown in [Table/Fig-2]. Associated Co-morbidity [Table/Fig-3] showed the pattern of cutaneous manifestations of Absent 124 41.3 80 80 diabetic patients which revealed that infections were the commonest, Present 176 58.7 20 20 as seen in 126 (42%) patients. [Table/Fig-4] showed the pattern of Pattern Co-morbidity infections among study group and control group which revealed Hypertension 130 43.3 15 15.0 that infections were less in the control group. In [Table/Fig-5] the frequency of infections had been compared with HbA1C levels in Dyslipidemia 83 27.7 5 5.0 the study group. It revealed that all the nine patients with multiple Coronary artery disease 33 11.0 1 1.0 infections had uncontrolled diabetes. Bronchial asthma 16 5.3 1 1.0 [Table/Fig-6] compared the pattern of bacterial infections in study Hypothyroidism 16 5.3 1 1.0 group patients and HbA1C levels. Furuncle was seen in 10 patients Tuberculosis 3 1.0 0 - and out of which 9 patients had uncontrolled diabetes. Carbuncle Dermatoses was diagnosed in one patient with uncontrolled diabetes. [Table/ Fig-7] revealed the pattern of fungal infections among study group Infectious 126 42 13 13.0 compared with HbA1C levels. Interestingly a life threatening infection, Non infectious 174 58 87 87.0 mucor mycosis was diagnosed in two patients who had uncontrolled No of Dermatoses diabetes. [Table/Fig-8] showed the detailed pattern of number of Single 246 82.00 97 97.0 infections among study group on comparison with HbA1C levels. All seven patients with two fungal infection had uncontrolled diabetes. Multiple 54 18.00 3 3.0 [Table/Fig-9] compared the pattern of viral infections among study HBA1C group with HbA1C levels. Out of eight patients with viral infections <6.4 59 19.7 100 100 six patients had uncontrolled diabetes. 6.5-7 70 23.3 0 - Pattern of dermatoses commonly associated with diabetes had 7.1-8 103 34.3 0 - been depicted in [Table/Fig-10]. Less common dermatoses were represented in [Table/Fig-11]. Pattern of the neuropathic and >8 68 22.7 0 - ischemic skin diseases
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