Dermatologic manifestations of diabetes mellitus

The prevalence of cutaneous manifestations of diabetes mellitus (both Type 1 and Type 2) ranges between 30 to 70%. The clinical features and underlying mechanism of these dermatologic features of diabetes mellitus will be described next.

Acanthosis nigricans

DescriptionPoorly delineated plaques with a grey to dark-brown pigmentation. Typically has a velvety texture.
LocationIntertriginous and other flexural areas (axilla, elbows, inframammary regions, palms – known as “Tripe palms”).
Mechanism• Insulin activates IGF-1 receptors present on fibroblasts and keratinocytes
• Additionally, hyperinsulinemia causes a decrease in IGF binding proteins, which results in a higher level of unbound (active) IGF-1 (vicious cycle)
• Androgens and growth factor receptors are present on keratinocytes and fibroblasts as well (may explain other hormonal causes of acanthosis nigricans)
Treatment• Improvement in insulin resistance (metformin, dietary changes, increased physical activity, and weight reduction)

Diabetic dermopathy

DescriptionHyperpigmented and circumscribed red papules that change over 1-2 weeks into atrophic brown papules
LocationPretibial area
MechanismNeuropathy and microangiopathy induced by uncontrolled diabetes mellitus
TreatmentIt is self-limited and largely asymptomatic, as such treatment is not required

Acrochordons (skin tags)

DescriptionPedunculated cutaneous fibromas
LocationFlexural areas in the neck and axilla, in a pattern akin to the distribution of acanthosis nigricans
MechanismHyperinsulinemia promotes the activation of fibroblast bound IGF-1 receptors present in the epidermis. This is followed by the proliferation of skin fibroblasts and subsequent development of skin tags.
TreatmentNo treatment is required

Necrobiosis lipoidica diabeticorum (NLD)

DescriptionA red-brown papule that progressively increases in diameter and eventually changes into the classic waxy, yellowish lesion. There is occasional central ulceration, which manifests as an atrophic center. Exhibits Koebnerization.
LocationPresent almost always on pretibial areas of the lower extremities
MechanismThere is initial tissue hypoperfusion in the skin due to microangiopathy involving skin capillaries. Microangiopathy occurs as a result of the accumulation of advanced glycated end products in the vasculature, which consequently promotes local oxidative stress. Inflammatory mediators which have accumulated in response to tissue hypoperfusion lead to a progressive breakdown in collagen
TreatmentTopical or intra-lesional corticosteroids


DescriptionLocalized lipodystrophy due to insulin injections is an umbrella term that consists of the lipoatrophy (LA) and lipohypertrophy (LH) subtypes. LA tends to appear as an area of subcutaneous tissue loss, which creates a dimple in the skin. LH, however, has a firm, rubbery consistency that is palpable in the subcutaneous tissue plane. Occasionally, LH lesions may be soft, making them difficult to discern on routine physical examination.
LocationSites of insulin injections
Mechanism• Lipoatrophy occurs as a result of an immune-mediated reaction to insulin; it is less prevalent now due to the use of modern human insulin or human-like insulin analogs.
• Lipohypertrophy is due to the growth-promoting effects of insulin on fibroblasts in the subcutaneous tissue. Insulin binds to IGF-1 receptors on fibroblasts which leads to the activation and subsequent proliferation of fibroblasts
TreatmentRotation of sites of insulin injection

Bullosis Diabeticorum

DescriptionSudden onset of one or more non-erythematous, firm and sterile bullae containing a clear fluid. They may range in size from 0.5cm to 5cm.
LocationUsually located on the lower extremities
TreatmentThese can be aspirated for symptomatic relief.

Scleroderma diabeticorum

DescriptionThickened, waxy, or edematous indurated plaques
LocationDistributed over the neck and upper back. Diabetic hand syndrome, a form of scleroderma-like skin change of diabetes, may present with limited joint mobility, palmar fibromatosis (Dupuytren's contracture), or stenosing tenosynovitis (“trigger finger”)
MechanismReduced breakdown of collagen fibers due to nonenzymatic glycosylation of dermal collagen

Eruptive xanthoma

DescriptionYellowish papules
LocationLocated over the trunk and extensor surfaces such as the elbows and knees.
MechanismReduced lipoprotein lipase activity due to insulin resistance or insulinopenia causes impaired storage of triglycerides in adipose tissue. As a consequence, triglycerides accumulate in the skin.
TreatmentTreatment of diabetes. Surgical treatment in select cases

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Duff M, Demidova O, Blackburn S, Shubrook J. Cutaneous manifestations of diabetes mellitusClin Diabetes. 2015;33(1):40-48. 

Images(s) Courtesy

Masryyy, CC BY-SA 4.0 , via Wikimedia Commons (Acanthosis nigricans)

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The MyEndoconsult Team. A group of physicians dedicated to endocrinology and internal medicine education.

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