Jurnal Kulit

LABORATORY OF DERMATOLOGIST JOURNAL READING
MEDICAL FACULTY MARET 2018

PATTIMURA UNIVERSITY
Skin Infections in Diabetes: A Review
MALYANTI MASRIN
NIM. 2017-84-026
Mentor:
Dr. Fitri K. Bandjar, Sp.KK., M.Kes
T-KL
ABSTRACT
 Diabetes mellitus (DM) constitutes a growing concern to world
population due to the devastating effects of its chronic
complications.
 An estimated number of people with diabetes are projected to
rise from 171 million in 2000 to 366 million in 2030.
 Glucose intolerance  results in ketoacidosis and
hyperglycemia causing immune dysfunction  predisposed to
cutaneous infections.
ABSTRACT
 If remain unnoticed, undiagnosed in the early stages or not treatment
properly such infections may get complicated and can even prove lethal.
 It therefore becomes imperative to recognize signs and symptoms of such
infections and approach them appropriately or refer the patient to a

diabetologist or dermatologist
Keywords: Diabetes mellitus; Hyperglycemia; Cutaneous infection.

Introduction
 Diabetes mellitus (DM)  comprises a group of metabolic disorders
exhibiting high blood sugar levels over an extended period.
 It is also characterized by state of relative or complete insulin
deficiency  leading to gross defects in glucose, fat and protein
metabolism.
 Diabetes is a major endocrine-related disorder causing severe
morbidity and mortality all over the world.
Introduction
 According to WHO report, an estimated number of people with diabetes are
projected to rise from 171 million in 2000 to 366 million in 2030.
 India shall gain ignominious reputation of ranking first (after China and USA)
to register 79.4 million diagnosed diabetic cases in 2030 from currently 62
million in 2015.
 Diabetes increases the susceptibility towards plethora of infections. The most
common sites of infection in diabetic patients  skin and urinary tract.
Introduction
 Patients with DM are more predisposed to skin infections such as 
folliculitis, furunculosis and subcutaneous abscesses.
 Sensory neuropathy, atherosclerotic vascular disease and hyperglycemia 
predispose patients with diabetes to skin and soft tissue infections  most
commonly involve the feet.
 Skin and soft tissue infections most common in patients of type-2 diabetes
mellitus with poor glycemic control.
Physiopathology
Decreased secretion of
Phagocytic mechanisms like
Interleukin-1 and Interleukin-6
leukocyte chemotaxis and
by mononuclear cells and
adherence are impaired
Monocytes.
hyperglycemia and
diabetic acidosis
Decreased secretion of
Interferes in the antimicrobial activity by
interleukin-10 by myeloid cells
inhibiting glucose-6- phosphate
and Interferon-γ and tumor
dehydrogenase (G6PD) enzyme
necrosis factor-α by T-cells
Skin infections
 Bacterial infections: Patients with DM are at an increased risk of
infection by some bacterial infections.
 Gram positive bacterial species  involving group A and B
streptococcal infections by streptococci group, Necrotizing fasciitis
caused by Group A streptococcus (Streptococcus pyogenes),
Staphylococcus aureus, Clostridium perfringens, Bacteroides fragilis, Vibrio
vulnificus, Aeromonas hydrophila and acute otitis externa (AOE) by
Pseudomonas aeruginosa.
Skin infections
 Group A streptococcal infections: It is an infection with group A
streptococcus (GAS), that is Streptococcus pyogenes  the risk of soft tissue
and skin infections found to be almost four times higher in patients with
diabetes.
 Group B streptococcal infections: Other invasive bacterial infections

like Group B streptococcus have also been associated with DM.
 Skin, soft tissue and bone (cellulitis, foot ulcers and decubitus ulcers)
are the frequently infected areas in Group B streptococcus infection.
Picture 1. cellulitis Picture 2. foot ulcers
Picture 3. Decubitus ulcers

Skin infections
 Staphylococcal infections: Staphylococcus aureus is a major pathogen
implicated in diabetic foot infections. Type-1 diabetic patients show more
frequent colonization of the nose and skin by S. aureus than non-diabetic and
non–insulin-dependent diabetic individuals.
 Acute otitis externa: Invasive (“malignant”) otitis externa is a quite rare

but potentially fatal infection of the external auditory canal and skull 
The acute form is caused primarily by P. aeruginosa and S. aureus.
Skin infections
 Necrotizing fasciitis: Necrotizing fasciitis (NF) is a rapidly progressive
inflammatory infection of the fascia, with secondary necrosis of the subcutaneous
tissues. The speed of spread is directly proportional to the thickness of the
subcutaneous layer.
 Necrotizing fasciitis has been classified as type I (infection caused by a combination

of anaerobic and one or more facultative aerobic organisms) or type II (caused by
group A streptococci, with or without staphylococci)
Skin infections
 The perineum, trunk, abdomen and upper extremities are most commonly
involved in Necrotizing fasciitis.
Picture 3. Necrotizing fasciitis.

Skin infections
 Fungal and yeast infections: In diabetic individuals, mycotic infections
might elevate the risk of manifesting diabetic foot syndrome.
 Patients with improperly controlled diabetes disease are more prone to
Mucocutaneous Candida infections.
 Correlation between localized candidal infection of the female genitalia
(vulvovaginitis) and diabetes have been found strongly correlated.
Fungal and yeast infections
 Studies have found out that infections of Candida balanitis, and
intertrigo (axillary, inguinal web space) in men are highly
indicative of underlying diabetes. Moreover, Glossitis,
Paronychia, and onychomycosis are quite frequent.
Picture 4.vulvovaginitis
Picture 5. onychomycosis
Fungal and yeast infections.
 Few studies suggest that the cases of rhinocerebral mucormycosis (RCM),
caused by zygomycetes (Mucor and Rhizipus species) are quite frequently
occurring in individuals with diabetes mellitus-mostly with diabetic
ketoacidosis.
 On an average, 50 percent of cases of rhinocerebral mucormycosis occur in
the diabetic patients.
Viral infections:
 Since long time, viruses have been suggested as a potential
environmental trigger for DM (typically type-1 diabetes).
 Viruses belonging to the Enterovirus genus have the capacity to initiate
and/or accelerate islet autoimmunity, but cannot fully explain the
etiology as a sole environmental trigger.
Conclusion
 Diabetic’s skin is more susceptible to skin infections uncommon in non-diabetics.
 Many of these infections require quick diagnosis and immediate treatment of the
severe complications or even fatal outcome is to be averted.
 With regard to the elevated frequency of skin manifestations in diabetic
individual’s and considering that they may lead to the development of the obvious
disease, specific consideration is advised towards these observations in high risk
individuals.
 In addition, superior metabolic control and employing innovative forms of insulin
and equipment will help alleviate many of these complications.
Skin manifestation in Diabetes
1. Necrobiosis lipoidica  the patient is at greater risk of
diabeticorum (NLD) developing ulcers.
• Is a necrotising skin condition that
usually occurs in patients with
diabetes mellitus but can also be
associated with rheumatoid arthritis.
• NLD appears as a hardened, raised
area of the skin. The center of the
affected area usually has a yellowish
tint while the area surrounding it is
a dark pink.
Picture. Necrobiosis lipoidica
diabeticorum (NLD)
2. Granuloma Annulare Place for predilection is the hand
The lesion almost resembles the NLD, but especially the radius of the dorsal
the GA does not occurs atrophy of the portion and lateral, and forearm.
epidermis. GA often occurs in children
and young adults, generally asymptomatic
and can heal itself.
The characteristics of the skin disorder are
characterized with red spots at an early
stage of expansion outward in a circle.
Picture Granuloma Annulare

3. Diabetic Dermopathy (DD)
• It is the most common skin disease
DM patients. Most common in men over 50
years of age. In DD there is a change of
vessels small blood.
• The lesion is a small macula (<1 cm) with
irregular shape, the surface is concave
(atrophy) and light brown, initially on the
anterior lower leg, but may also be affected
upper arms, thighs and bone protrusions. Picture Diabetic Dermatopathy
4. Acanthosis Nigricans The skin is exposed looks dirty and
• Akantosis nigrikans seen in DM patients. the surface looks like velvet, usually
symmetrical. The back of the neck is
• Clinically nantric akantosis nigrikans appear as
the part most commonly affected.
thickening skin with brownish papules until
blackish on the crease area like the back neck,
armpit, groin, breast crease and folds
stomach.
Picture Acanthosis Nigricans

5. Diabeticorum bullosa The size of the bull varies from,
• Very rare, but characteristic in patients usually bilateral, the bull contains clear
DM. sterile fluid and no erythema around
it, no painful and itchy and may
• The bull appears spontaneously,
disappear in time several weeks (2-5
usually in the dorsum area of the lower
weeks) without scar.
limbs and legs, sometimes can also
occur on the arm down and hand.
Picture Diabeticorum Bullosa

Clinical manifestation in Diabetes
6. Xhantomatosis
• Clinical manifestations of
xantomatosis include papules
yellowish red sized 1 to 4 mm lies
in the buttocks and extremities of
the extensor parts.
• These lesions usually arise in
Picture. Xhantomatosis
groups and can form
plaque over time
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LABORATORY OF DERMATOLOGIST JOURNAL READING

MEDICAL FACULTY MARET 2018

Skin Infections in Diabetes: A Review

 It therefore becomes imperative to recognize signs and symptoms of such

infections and approach them appropriately or refer the patient to a

Keywords: Diabetes mellitus; Hyperglycemia; Cutaneous infection.

 Group B streptococcal infections: Other invasive bacterial infections

Picture 3. Decubitus ulcers

 Acute otitis externa: Invasive (“malignant”) otitis externa is a quite rare

 Necrotizing fasciitis has been classified as type I (infection caused by a combination

Picture 3. Necrotizing fasciitis.

Picture Granuloma Annulare

Picture Acanthosis Nigricans

Picture Diabeticorum Bullosa

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