VOLUME 10 NUMBER 2 • JUNE 2013
53
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Scleroedema diabeticorum
Scleroedema diabeticorum (Fig. 4) is an unusual condition occurring
in 2.5% to 14% of people with DM and seems to be more common
in men than women. It is characterised by a symmetrical diffuse
induration of the upper part of the body, in particular the posterior
neck and upper back, with overlying redness. The skin often has
a
peau d’orange
appearance. Occasionally, the induration may
extend to the deltoid and lumbar regions. Onset is subtle and
the involvement is persistent with no specific treatment available.
Histologically, it is characterised by a thickened dermis with thick
collagen bundles and mucin deposition. Diabetes control has no
influence on the prognosis. No effective treatment is known for
scleroedema diabeticorum although sparse reports of phototherapy
affording some relief can be found in the literature.
diagnosis. Thorough evaluation regarding the vascular status of
the patient should be performed by appropriate specialists. Simple
wound care, combined with occasional debriding agents if needed,
and careful surveillance for secondary infection is important in the
management of the ulcers. An experienced wound care nursing
sister can be invaluable in this regard.
Granuloma annulare
Granuloma annulare (GA) (Fig. 5) and its association with DM
are controversial. Some studies have been able to demonstrate a
stronger association between generalised, chronic relapsing GA
and DM versus the localised variant of GA and DM. The cause
is unknown. The lesions start as red papules, which expand
centrifugally and resolve centrally, resulting in annular or polycyclic
plaques. The dorsa of the hands and arms are the sites usually
affected. The histology is comparable to that of necrobiosis lipoidica
except for the presence of mucin in GA. Localised lesions often
resolve spontaneously, whereas the generalised form has a more
protracted and relapsing course and rarely shows spontaneous
resolution. Treatment options include corticosteroids (topical,
intralesional or systemic) and phototherapy amongst others.
Figure 4.
Scleroedema diabeticorum.
The lighter crease in the mid back is often found in skin conditions associated
with induration/thickening of the skin.
Diabetic bullae
Diabetic bullae, also known as bullosis diabeticorum, are very
rare occurring in 0.5% of diabetic patients. It is found more
commonly in those with type 1 DM, in men and in patients with
longstanding diabetes and peripheral neuropathy. The bullae appear
spontaneously, commonly on the dorsa and sides of the lower legs,
especially the feet. Occasionally, similar lesions may be found on
the forearms and hands. Bullae may range from millimeters to a
few centimeters. The lesions are often bilateral, containing clear
sterile fluid, with no surrounding erythema. These blisters are not
the result of trauma or infection and this is a diagnosis of exclusion.
The cause of this rare manifestation of diabetes is unknown.
Treatment is symptomatic and conservative. In cases of discomfort,
the bullae can be aspirated leaving the blister roof intact. Most
lesions resolve in 2 to 3 weeks without residual scarring, although
they may recur.
Lower leg ulcers
Although the neuropathic ulcers are the type of ulcer that comes
to mind when considering diabetes, one has to remember that the
commonest ulcer by far still remains venous insufficiency ulcers.
Due to the macrovascular complications associated with diabetes,
arterial ulcers also need to be considered in the differential
Conclusion
Recognising skin signs in DM are important because they may be the
initial clues to the diagnosis, they may portend advanced disease,
they may lead to severe discomfort and impairment in the quality
of life of the patient; and they may even contribute to the patient’s
demise. Assistance of a dermatologist in the management of patients
with DM may be invaluable and is certainly advisable in many cases.
Further reading
1. Van Hattem S, Bootsma AH, Thio HB. Skin manifestations of diabetes.
Clev Clin J
Med
2008;
75
(11):772-787.
2. Ahmed I, Goldstein B. Diabetes mellitus.
Clin Dermatol
2006;
24
:237–246.
3. Ferringer T, Miller F. Cutaneous manifestations of diabetes mellitus.
Dermatol Clin
2002;
20
:483–492.
4. Sreedevi1 C, Car N, Pavliæ-Renar I. Dermatologic lesions in diabetes mellitus.
Diabetologica Croatia
2002;
31
(3):147-159.
5. Perez MI, Kohn SR. Cutaneous manifestations of diabetes mellitus.
J Am Acad
Dermatol
1994;
30
:519–530.
6. Jelinek JE. Cutaneous manifestations of diabetes mellitus.
Int J Dermatol
1994;
33
:605–617.
Figure 5.
Granuloma annulare.
GA starts as a non-scaly red papule, spreads centrifugally and clears centrally to
form polycyclic plaques.
