|Year : 2017 | Volume
| Issue : 2 | Page : 52-55
In search of cutaneous marker for retinopathy in diabetic patients: A pilot study
Banavasi S Girisha1, Neethu Viswanathan2
1 Department of Dermatology, Venereology and Leprosy, Justice K S Hegde Charitable Hospital, Mangalore, Karnataka, India
2 Consultant Dermatologist, Payyanur, Kerala, India
|Date of Web Publication||28-Jul-2017|
Banavasi S Girisha
Department of Dermatology, Venereology and Leprosy, Justice K S Hegde Charitable Hospital, Derlakatte, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Diabetes mellitus is one of the most common causes of microangiopathy. Approximately 30% of all diabetics show skin lesions during their lifetime. However, there is a paucity of data on the association of diabetic retinopathy with the skin changes. Objectives: The aim is to study noninfectious diabetes associated dermatoses in patients with diabetic retinopathy and to compare the frequencies of dermatoses in diabetics with retinopathy, diabetics without retinopathy and nondiabetics. Materials and Methods: We screened 400 diabetic patients and found 145 diabetics with cutaneous manifestations were positive for diabetic retinopathy after fundoscopic examination by a qualified ophthalmologist. One hundred and forty-five age- and sex-matched diabetics with cutaneous manifestations and without retinopathy, and another 145 age- and sex-matched nondiabetics with normal random blood sugar (RBS) levels and cutaneous manifestations formed the control groups. Statistical analysis was performed using SPSS version 16 and Chi-square test. Results: Acquired ichthyosis was the most common finding which was seen in 70 (48.27%) diabetics followed by acrochordons in 18 (12.41%) diabetics. Other noninfectious dermatoses associated with Diabetic Mellitus seen among the cases include diabetic foot in 7 (4.8%), psoriasis in 5 (3.44%), acanthosis nigricans in 4 (2.75%), pruritus in 3 (2.068%), vitiligo in 3 (2.068%) patients, Kyrle's disease in 3 (2.068%), and diabetic bullae in 2 (1.37%) patients. Conclusions: Diabetic retinopathy is not an uncommon cause of ocular morbidity. Our observation calls for the need of a holistic approach toward the diagnosis and treatment of diabetes and diabetes-associated skin and systemic complications.
Keywords: Diabetic retinopathy, glycemic control, noninfectious dermatoses
|How to cite this article:|
Girisha BS, Viswanathan N. In search of cutaneous marker for retinopathy in diabetic patients: A pilot study. Clin Dermatol Rev 2017;1:52-5
| Introduction|| |
Diabetes mellitus (DM) is the most common endocrine disorder in the world and is known to affect 8.3% of the population. The International Diabetes Federation has observed the total number of diabetic subjects to be around 40.9 million in India, and this is expected to come up to 69.9 million by the year 2025. In general, the macrovascular complications include coronary artery disease, peripheral arterial disease, and stroke and microvascular complications include diabetic nephropathy, neuropathy, and retinopathy. Hyperglycemia, high blood pressure, and hypercholesterolemia are potential risk factors for the development of diabetic retinopathy. A good glycemic control was found to be associated with decreased development and progression of diabetic retinopathy in patients.
Skin manifestations in DM patients are very common and well known. Approximately 30% of all diabetics show skin lesions during their lifetime. However, there is a paucity of data on the association of diabetic retinopathy with the skin changes.
- To determine the noninfectious diabetes associated dermatoses in patients with diabetic retinopathy
- To compare the frequencies of noninfectious diabetes associated dermatoses in diabetics with retinopathy, diabetics without retinopathy and nondiabetics.
| Materials and Methods|| |
This study was a hospital-based case–control study. Institutional ethical clearance was obtained before start of the study. Authors evaluated 400 type 2 diabetes patients and 400 nondiabetic patients for various skin manifestations. Cutaneous infections were present in 37% of diabetic patients and rest were noninfective dermatoses. Nonproliferative diabetic retinopathy was found in 145 (36.25%) patients. These 145 patients formed the study cohort, and cutaneous changes were evaluated in them. The fundoscopic examination was carried out by a qualified ophthalmologist. One hundred and forty-five age- and sex-matched diabetics with cutaneous manifestations and without retinopathy, and another 145 age- and sex-matched nondiabetics with normal RBS levels and cutaneous manifestations formed the control groups. All individuals in the study were screened for noninfectious diabetes associated dermatoses. Complete physical examination of the patients along with a local examination of lesions was done.
Patients with type 1 DM, HIV, malignancies and those on dialysis and those not consenting to participate in the study were excluded from the study.
According to the severity of diabetic retinopathy, our patients were placed under mild, moderate, and severe grades. Diabetics with hemoglobin A1c (HbA1c) <7% were placed under the good glycemic control group and those with HbA1c ≥7% were placed under the poor glycemic control group.
All details were entered in prestructured pro forma. Statistical analysis was performed using SPSS version 16 (SPSS Inc. Chicago, USA) and Chi-square test.
| Results|| |
Among the 145 cases studied, 95 (65.51%) were males, and 50 (34.48%) were females with a male to female ratio of 1.9:1. The mean age of the population in our study was 58.28 years ± 11.36. The majority of patients had DM for more than 10 years (42.06%).
Hypertension was the most common among the associated comorbid illness [Table 1].
Most of the diabetic patients were on oral hypoglycemic drugs followed by those on insulin. None of the patients were only on diet control as the mode of treatment. Poorly controlled diabetics (79.3%) formed the majority of the study.
The number of patients with mild nonproliferative diabetic retinopathy were 95 (65.5%) and those with moderate nonproliferative diabetic retinopathy were 45 (31.03%). Severe nonproliferative diabetic retinopathy was seen in 5 patients who accounted for 3.44% of the total.
Among the cases, acquired ichthyosis was the most common finding which was seen in 70 (48.27%) diabetics followed by acrochordons in 18 (12.41%) diabetics. Other noninfectious dermatoses associated with diabetic mellitus seen among the cases include diabetic foot in 7 (4.8%), psoriasis in 5 (3.44%), acanthosis nigricans in 4 (2.75%), pruritus in 3 (2.068%), vitiligo in 3 (2.068%) patients, Kyrle's disease in 3 (2.068%), and diabetic bullae in 2 (1.37%) patients. [Table 2] shows the frequencies of cutaneous manifestations in cases and controls. Acquired ichthyosis, acrochordons, and diabetic foot were more among cases than the control groups, and the P values were statistically significant [Table 2].
|Table 2: Cutaneous manifestations associated with diabetes mellitus (with/without retinopathy) and nondiabetic controls|
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| Discussion|| |
DM is a metabolic disorder characterized by increased fasting and postprandial blood glucose levels with a variety of multisystem complications. Skin manifestations are frequently seen in DM and sometimes may be the presenting signs which help in the early diagnosis of the disorder. Abnormal carbohydrate metabolism, microangiopathy, atherosclerosis, neuronal degeneration, and impaired host mechanisms play a role in the development of skin complications.
Among the comorbid illnesses noted in the study, hypertension was the most common seen in more than half (53.10%) of the study group followed by dyslipidemia in 25.5%. This along with uncontrolled diabetes melitus can cause microvascular complications either mutually exclusive or synergistically. Al-Mutairi et al. and Tseng et al. also observed that hypertension was the most common associated illness in their studies., Majority of our patients had diabetes of duration more than 10 years. Out of the 5 patients with severe diabetic retinopathy in our study, all 5 had poorly controlled diabetes with hypertension, and 4 of 5 had diabetes of duration 10 years and more. Poorly controlled diabetics (HbA1C ≥7%) formed the majority, i.e., 79.3%. It has been reported that hyperglycemia, increased duration of diabetes, increased blood pressure and hypercholesteremia are risk factors for diabetic retinopathy. Advanced glycosylated end-products (AGEs) which develop following prolonged hyperglycemia, oxidative stress, growth factors, and aldose reductase enzyme are thought to be associated with diabetic retinopathy. In this study, diabetic retinopathy with cutaneous manifestations was seen in 36.25% of patients. This is comparable to study by Nigam and Pande who observed diabetic retinopathy in 32.8% of diabetic patients with skin manifestations. However, Mahajan et al. observed diabetic retinopathy along with cutaneous lesions in 12.5% of diabetic patients.
Other microvascular complications seen along with retinopathy are neuropathy and nephropathy, which were seen to occur under poor glycemic control. As with diabetic retinopathy, the risk of developing diabetic neuropathy and nephropathy is proportional to both the magnitude and duration of hyperglycemia.
Acquired ichthyosis occurring predominantly on shins was the most common finding seen in our study, i.e., in 48.27%. Ragunatha et al. observed ichthyosis only in 1.2% of the patients. Acquired ichthyosis is probably caused by an increase in the production and accumulation of AGEs in the skin of diabetic patients and autonomic neuropathy. A higher number of cases were found to have acquired ichthyosis compared to controls which was statistically significant (P ≤ 0.00001). Acrochordons and acanthosis nigricans which were seen in 12.41% and 2.75% of the patients, respectively, are signs of insulin resistance and hyperinsulinemia. Bhargava et al. proposed that increased un-esterified fatty acids due to hyper-insulinemic state could cause an overexpression of epidermal growth factor receptors causing acrochordons. Kataria and Chhillar observed acrochordons in 18% of the patients. Acrochordons were much higher among diabetics with diabetic retinopathy than diabetics without diabetic retinopathy and nondiabetics which was statistically significant (P = 0.007). Acanthosis nigricans has been established as a risk factor for type 2 DM and is also a marker for metabolic syndrome. The diabetic foot was observed in 4.8% of the patients. Rao et al. found diabetic foot in 4% of the patients. Diabetic foot was also more among cases compared to controls which was statistically significant (P ≤ 0.001).
Our study reveals an increased association of diabetic retinopathy with cutaneous manifestations such as acquired ichthyosis, acrochordons, and diabetic foot. Furthermore, there is a paucity of data showing an association of skin lesions with microangiopathic complications; which thereby sets this study apart.
Limitations of our study
- It is a pilot study with a small number of patients
- The number of patients with severe retinopathy was very low
- Infectious dermatoses were excluded.
| Conclusions|| |
Diabetic retinopathy is not an uncommon cause of ocular morbidity. This study shows an increased association of diabetic retinopathy with uncontrolled hyperglycemia, increased duration of diabetes and hypertension. It also shows an increased prevalence of diabetes associated dermatoses in patients of diabetic retinopathy and poorly controlled diabetes. Acquired ichthyosis, diabetic foot, and acrochordons were significantly higher among diabetics with retinopathy than diabetics without retinopathy and nondiabetics. A significant association was found in our study. Our observation calls for the need of a holistic approach towards the diagnosis and treatment of diabetes and diabetes-associated skin and systemic complications. A liaison between general medicine, dermatology and ophthalmology will help reduce the morbidity and mortality associated with this disorder.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]