Skin is the largest organ in your body. Many people with diabetes are more likely to develop skin problems. While some are minor and mainly cosmetic, others can be fatal.
“Diabetes tends to dry out the skin as part of the disease process,” said Jeffrey Meffert, MD, program director, dermatology at University Health System’s Diabetes Institute in San Antonio, Texas. “Some of the medications used can make the problem worse.”
When blood sugar is high the body loses fluid, causing the skin to become dry. Dry skin in diabetes is related to damage to the nerves that cause sweating, the body’s main lubricating system.
Type 1 diabetes is an autoimmune disorder in which the immune system attacks and destroys the insulin-producing beta cells in the pancreas. As a result, the pancreas produces little or no insulin. Type 1 diabetes is also characterized by the presence of certain autoantibodies against insulin or other components of the insulin-producing system such as glutamic acid decarboxylase (GAD), tyrosine phosphatase, and/or islet cells.
When the body does not have enough insulin to use the glucose that is in the bloodstream for fuel, it begins breaking down fat reserves for energy. However, the breakdown of fat creates acidic by-products called ketones, which accumulate in the blood. If enough ketones accumulate in the blood, they can cause a potentially life-threatening chemical imbalance known as ketoacidosis.
Type 1 diabetes often develops in children, although it can occur at any age. Symptoms include unusual thirst, a need to urinate frequently, unexplained weight loss, blurry vision, and a feeling of being tired constantly. Such symptoms tend to be acute.
Diabetes is diagnosed in one of three ways – a fasting plasma glucose test, an oral glucose tolerance test, or a random plasma glucose test – all of which involve drawing blood to measure the amount of glucose in it.
Type 1 diabetes requires insulin treatment for survival. Treatment may also include taking other drugs to prevent kidney damage or to treat diabetes-related conditions such as high blood pressure.
Dry skin can lead to many major concerns in diabetes. Cracking and peeling results in openings in the skin, allowing bacteria or fungi to enter the body. High levels of sugar in the body are great breeding grounds and reduce your body’s ability to heal itself, increasing the chances an infection may spread.
Several different kinds of bacterial infections occur more often in people with diabetes. Among these are:
• styes in the glands of the eyelids;
• folliculitis of the hair follicles;
• carbuncles — very deep infections of the skin and underlying tissue; and
• infections around the nails.
“With bacterial infections, you most often first see a redness around the area of the cut or crack,” said Matthew G. Garoufalis, DPM, a podiatrist in private practice in Chicago. “People with diabetes are at a disadvantage because they often will not feel pain, which can be an early warning that an infection is occurring. As it progresses, you may also see drainage from the wound, and it may become warm to the touch.”
Fungal infections also are a concern. Most often, the organism in skin folds is Candida albicans. This is a yeast-like fungus that creates a rash of moist, red areas surrounded by tiny blisters. They occur most often in warm and moist areas. Other common fungal diseases include jock itch, athlete’s foot, ringworm and vaginal infections.
An ulcer is an open wound large enough that deeper structures including the bone itself can be seen. They most often occur on those areas getting the most pressure, such as the ball, heel and side of the foot. Ulcers also can occur on other pressure points or can be secondary to a cut or scrape that doesn’t heal properly.
People with diabetes are more likely to develop ulcers for many reasons. Blood vessel problems mean the area already is starved and breaking down. The lessened blood supply also can lead to an inability to get antibodies and other infection fighters to the ulcer.
Nerve damage from diabetes also contributes to the formation of these deep wounds. In this case, the pain that serves as a warning sign of problems may not be felt, lessening the chances they will be found early. Also, if you can’t feel tingling sensations, you may be applying pressure to an area and cutting off the blood supply without knowing it.
“Skin ulcers are the main reason people lose extremities,” said Meffert, who also is an associate professor of dermatology and cutaneous surgery at the University of Texas Health Science Center San Antonio. “If not treated immediately and aggressively, they don’t heal properly and keep killing off tissue deeper and deeper. Once it gets to bone, you are now at greatly increased risk of amputation.”
If damage reaches that level, it can cause not only disability, but also loss of life.
“If a person has an amputation, the survival rate drops dramatically,” said Garoufalis. “We see between 40% and 80% dying within five years. It is very crucial to stop infections, heal ulcers, and restore blood flow as soon as possible.”
Both Garoufalis and Meffert agree the best way to avoid skin problems of all kinds is to maintain tight control of your blood sugar. This lessens the dryness and the chances of an opening for bacteria to enter your body. Good control helps preserve immune function, so you can better fight off an infection before it spreads. Lower average blood sugars also lessen the nerve and vessel damage that leads to ulcers and skin breakdown.
“Control of diabetes has an effect on skin quality, quality of circulation, your perception of pain and other sensations and your ability to fight off infection,” said Garoufalis. “Having normal blood sugars is a key to long survival.”
Another important aspect of preventing skin problems is to eyeball your body on a daily basis. Look for red spots, blisters and sores that can lead to infection. Pay special attention to the bottoms of your feet and between your toes.
“Daily inspection of some areas is hard, but you can use a mirror to study what you can’t easily see directly to find the physical manifestations of break down or infection,” noted Garoufalis. “Relatives or others can be recruited to assess the places you can’t. Paying attention to the very small details, and making a habit of it, is very important for the diabetes patient.”
There are a number of other ways to help prevent skin problems.
• Wash thoroughly with a mild soap in warm water. Harsh soaps can dry the skin. Hot water is a concern because it can burn the skin.
• Make sure you completely dry your body, especially between the toes, to avoid giving fungus a place to grow.
• Use sunscreen with a level of SPF 15 or above, even if the sun isn’t out. Ultraviolet rays can damage your skin, and it is important to avoid sunburn. In addition, some diabetes medications such as glyburide (brand names Diabeta, Micronase, and Glynase), glipizide (Glucotrol and Glucotrol XL), and glimepiride (Amaryl) can make you even more sensitive to sunburn.
• Drink lots of fluids, especially water, to help keep your skin moist.
• If you live in an area of low humidity or your home has a dry heating system, use a room humidifier to add moisture to the air.
• Wear warm gloves and footwear when the temperature drops.
• Wear white cotton underwear. Cotton lets air move, and there are no dyes or other chemicals that might cause a rash.
• Use a moisturizer to keep the skin supple and prevent cracking.
“You do not need to spend a lot of money on high-end, brand-name skin products,” said Garoufalis. “Any kind of skin moisturizer is good, as long as you make a habit out of using it. The expensive stuff is wonderful but not usually needed for maintenance. If you need more than routine maintenance, you most likely will need a prescription anyway.”
For the most part, it is safe for you to do much of your own general work on your feet and hands. If your nails are normal, cutting them straight across should pose no problem. However, if you have an ingrown toenail, it is best to see a podiatrist. The same suggestions hold if you have a fungal infection of the toenail.
The same guidelines are in place for removing excess skin. Careful use of a pumice stone or emery board should pose no problems if your diabetes is in good control and you aren’t having any nerve concerns.
In most cases, there is no need to use an antibiotic moisturizer. They usually are not only more expensive, but also harsher and destroy the normal flora on your skin that helps protect it.
Because they are further from the heart, and because they support the weight of your body, your legs and feet are more likely to have skin breakdowns and resulting concerns. Selection of shoes and boots is very important to proper skin care.
“Unfortunately, the best shoes for diabetics are the ugly ones,” said Meffert. “They need to have a wide toe box, and high heels are not a good idea because they tend to shove the foot into a small area, which can lead to blisters. They need to be wide enough so the toes don’t feel cramped, but if they are too loose, they can give you blisters.”
You also should be careful with socks. Heavier ones can cause your foot to sweat, resulting in fungal growth. If the seam is not properly placed, or there is a wrinkle, the pressure can result in breakdown of your skin. This is another instance in which nerve damage can mean you won’t recognize the problem until you do your daily inspection.
Unfortunately, it is almost impossible to prevent all problems. It is important to make sure small cuts stay that way.
If you have a small cut, gently wash the area with mild soap and water, making sure you dry it completely. Cover the cut with a cloth bandage or one the packaging says is hypoallergenic. Change the bandage at least once a day. Ask your doctor for a recommendation about using antibiotic ointments. The same interventions can be used for other minor skin irritations.
If you have a minor burn, never pop the blister. Again, wash the area, put on a bandage and change it at least once a day.
“This is not an emergency room situation,” said Garoufalis. “You need to be vigilant, but there is no need to panic. However, if things do not get better or become worse, see a doctor as soon as you can.”
You should call your podiatrist or other health-care provider if:
• there is no improvement by the next day;
• pain or other discomfort lasts more than two days;
• an ulcer develops or you develop a fever; and/or
• you notice any kind of discharge coming from near or out of the sore.
In addition to these major problems that can occur secondary to diabetes, others exist that tend to be more benign but still troubling.
• Ascanthosis nigricans, in which tan and brown raised areas appear on the skin near the armpit, neck, and groin. These are seen most often in overweight individuals, and the best treatment is to lose weight.
• Eruptive xantomatosis appears as firm, yellow bumps in the skin about the size of a pea and usually results in itching. It is seen usually in young men with type 1 diabetes who have higher levels of cholesterol and fat in their blood. Gaining control of your diabetes is the best treatment.
• Digital sclerosis is tight, thick, waxy skin on the backs of the hands, toes, and forehead. resulting in finger joints becoming stiff. Treatment usually is getting your diabetes under control.
• Disseminated granuloma annulare results in ring-shaped red, brown or skin-colored areas in the extremities. See your doctor if you have rashes like these, as there are drugs that can treat this condition.
“As you age, those with diabetes will still get the same skin issues of others in their group,” said Meffert. “If you keep your diabetes under good control, you will be less likely to have the important ones that can lead to disability or death, compared to those who don’t.”
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