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Diabetes mellitus may be associated with dermatological lesions affecting the skin and mucous membranes. In some cases they may even provide the physician with a first indication that the patient may be suffering from diabetes. Typical examples include necrobiosis lipoidica, granuloma annulare, acanthosis nigricans and vitiligo.
Many endocrine diseases are accompanied by skin damage. It is induced by initial hormonal and metabolic disorders, manifestates at the early stage of the disease and represents very important diagnostic sign. Clinical peculiarities of diabetes mellitus dermal manifestations in children are presented in this review paper. Number of dermatosis are discussed which are mainly due to the disturbances of carbohydrate metabolism (skin itching, pioderma, candidosis, xanthochromia, eczema, psoriasis, necrobiosis lipoidica, granuloma annulare, xanthomatosis, black acanthosis, porphyria). Author suggests that during examination of children with different type of dermal pathology, dermatologist must suspect existence of diabetes mellitus and should investigate such cases for the presence of this disease. In other words, dermatologist can contribute in the early revelation of diabetes mellitus in children.
Even a half of diabetic patients are suffering from skin troubles. Hyperglykemia causes skin changes leading to higher incidence of bacterial and mycotic infections, provokes skin degenerative processes, macro- and microangiopathy and neuropathy. Diabetic dermopathy, rubeosis, bullousis and scleredema are based on these changes. Other skin diseases including necrobiosis lipoidica, granuloma anulare, vitiligo, perforating folliculitis accompany diabetes frequently but their etiopathogenesis is not clear.
Patients with the following diagnoses were presented: pyoderma gangraenosum in a patient with myelodysplastic syndrome passing into an acute myelomonocytic leukemia and specific cutaneous infiltration, primary genital infection with herpes simplex virus, type 1 (HSV-1) in an adult patient, pellagroid, Sweet's syndrome with follicular involvement, Sweet's syndrome in a patient with cancer of the breast, lichen amyloidosus, angiolymphoid hyperplasia with eosinophilia, Darier's disease 1. associated with basal cell carcinoma 2. with specific cutaneous infiltrations in a patient with acute myeloid leukemia, body building, anabolic steroids and fertility, multiple trichodiscomas and perifollicular fibromas, Buschke's scleroedema adultorum, extensive necrobiosis lipoidica without diabetes mellitus, extramammary, multifocal type of Paget's disease.
Lotions of five different corticosteroids were applied on 3 X 4 cm areas of large infiltrated chronic psoriatic plaque in eight patients, and left occluded with a hydrocolloid dressing (Actiderm) for one week. Area treated with clobetasol, betamethasone and triamcinolone were clinically healed within one week in four patients, but slight residual erythema was observed in the other four. Hydrocortisone-treated areas showed better improvement than the non-steroid-treated control area, where infiltration and erythema remained unchanged. In 44 patients with psoriasis, lichen planus, chronic lichenified eczema, discoid lupus erythematosus and necrobiosis lipoidica, treatment with betamethasone applied 1-3 times under Actiderm once a week healed the lesions. The skin-coloured Actiderm is easy to apply and wear and does not loosen when taking a shower or hot bath.
The expression of the CD36 (OKM5) antigen was studied with the PAP technique on sections of skin from healthy subjects and of normal and diseased skin from patients with various skin diseases. In specimens from healthy subjects the antigen was found on vascular and perivascular structures and in some cases it was seen on cells of the acrosyringium. A net-like pattern of CD36 was observed in the upper part of the stratum spinosum in skin lesions of patients with psoriasis, lichen planus, pityriasis rosea, morbilliform drug reactions, necrobiosis lipoidica, lichen amyloidosus, Darier's disease and ichthyosis vulgaris. Expression of CD36 was also seen in the nonlesional skin just below the granular layer in 3 of 5 patients with factitial urticaria with immediate dermographism, but not in delayed dermographism or chronic urticaria. In ichthyosis vulgaris CD36 was also expressed in dendritic cells of the basal layer and in a patient with a graft versus host reaction it was recognized both on scattered keratinocytes and on dendritic cells in the epidermis. The role of the expression of the CD36 antigen in the skin is unknown. The activated cells might possibly serve as antigen-presenting cells and/or have a modulatory influence on an inflammatory reaction.
The aim of dermatologic check-up is the early diagnosis of asymptomatic potentially dangerous skin changes. An early melanoma may be cured by simple excision. Dermatologic signs in general medicine are very important. Paraneoplastic symptoms in patients with glucagonoma consist of the typical necrolytic migratory erythema. Acrokeratosis Bazex is seen in patients with larynx carcinoma and dermatomyositis or acanthosis nigricans may occur in patients with internal malignancy. Spider angioma, jaundice, changes in hair pattern and white nails may be cutaneous signs of liver disease or necrobiosis lipoidica may be found in diabetic patients. Renal transplants and patients with HIV infection should be submitted for a dermatological check-up every six months. In these people several malignant tumors are seen more often than in control people.
The classical histological features of rheumatoid nodules are similar to those of subcutaneous granuloma annulare and necrobiosis lipoidica. The same applied to the DIF images of these lesions. Rheumatoid nodules are more frequent in patients with high rheumatoid factor. Lesions of cutaneous vasculitis are a sign of severity associated with other extra-articular manifestations. Our results are consistent with those of other studies which demonstrated the presence of Ig and/or C deposits in vessels and sometimes at the dermis-epidermis junction. The deposits found in vessels are usually formed of IgM and C3, more rarely of IgG. Those found at the dermis-epidermis junction consist of IgG, IgM and C3. Immune complex deposits in the walls of venules represent the primary mechanism of leukocytoclastic vasculitis. The presence of such deposits on vessels with muscular wall in rheumatoid arthritis suggests an identical pathogenetic mechanism. No alteration of the basal membrane has been noted. The role of deposits at the dermis-epidermis junction has not yet been elucidated.
Pseudo-scleroderma should not be confused with true scleroderma, the prognosis of which is unpredictable and often serious. Progressive acrosclerosis must be differentiated from Raynaud's disease, congenital or hereditary disorders of unknown aetiology: Werner's syndrome, acrogeria and progeria; Rothmund-Thomson's syndrome, Steinert's disease, phenylketonuria, disorders of glycogen metabolism; metabolic disorders: mutilating acropathies, scleromyxoedema, porphyria cutanea tarda; occupational and iatrogenic disorders: acroosteolysis, toxic epidermic syndrome (Spain), scleroderma-like change induced by bleomycin, chronic graft-versus-host disease; and leprosy. Acute diffuse scleroderma should not be confused with Buschke's scleroedema, sclerema neonatorum, systemic amyloidosis and scleroderma-like changes in hypothyroidism. Linear pseudo-scleroderma is suggested by the following scleroderma-like conditions: facial hemiatrophy, acrodermatitis atrophicans, melorheostosis, pseudo-scleroderma after corticosteroid injection, and cutaneous lesions in carcinoid syndrome. Scleroderma in plaque must be differentiated from hypodermitis sclerotisans, panatrophy and localized lipoatrophies, hypodermitis after vitamin K injection, basal cell carcinoma, necrobiosis lipoidica, vitiligo, chronic radiodermatitis, cutaneous lymphatic invasion. Scleroderma-like changes after drug injection (vitamin B12, progestin), anetoderma barely resemble morphea guttata.
We report three cases of 54, 58 and 65-year-old patients presenting annular lesions with centrifugal migratory extension. They occur exclusively on sun-exposed areas. In two cases, the lesions were multiple. In the third case, the lesion was single and mimicked an erythema annulare centrifugum. The past history ranged from 18 months to 8 years. Microscopic examination of the central part showed a disappearance of elastic fibers in upper reticular dermis. Examination of the ring showed in upper reticular dermis an histiocytic granulomatous infiltration with many giant cells, lymphocytes and patterns of elastic fibers phagocytosis. Similar features were found by electronmicroscopy. These three cases illustrate the typical features of O'Brien's actinic granuloma. Relationship between this actinic granuloma and granuloma annulare occurring on sun-exposed areas on one side, and necrobiosis lipoidica, Miescher's granuloma and granuloma multiforme on the other side, are discussed. On the basis of some clinical and histological patterns, the autonomy of O'Brien's actinic granuloma appears to be established.
After a short exposition of the meaning and the technique for determination of immune complexes in circulating blood (after Hashkova, with polyethylene glycol) our first experience with phlebological patients is exposed. Positive reactions in a variety of cases (N = 122) includes atypical ulcus cruris, ulcerated vasculitis, Pyoderma gangrenosum, discoid lupus erythematodes, chronic rheumatoid polyarthritis (with, or without ulcus cruris), monoarthritis of the knee, pernicious anemia, chronic lymphedema (elephantiasis), some cases of sclerosis multiplex. In such positive cases the sedimentation rate of citrate blood may, or may not be elevated. Negative or uncertain reactions (below 10) were seen in 141 cases, in common's ulcus cruris cases, in vasculite nodulaire, in discopathy and most spondylarthroses and other arthrosis cases, in vasculite nodulaire, in discopathy and most spondylarthroses and other arthrosis cases, in various patients with rheumatoid complaints in coxarthrosis, osteoporosis and in a group of healthy young persons. Negative reactions were the rule in atherosclerotic and diabetic old persons with claudication or gangrene, in most dermatological cases, in necrobiosis lipoidica, in psoriasis, in postthrombotic phlebitis and in chronic rheumatism in a quiet stage. In vasculitis cases the reaction is often only slightly positive (between 10 and 20) but should be repeated as the values may vary. The determination of circulating immune complexes with polyethylenglycol is a useful screening method in the policlinic. Treatment is often directed in the right way sometimes prednisone, more often nivaquin (chloroquin) or other anti-inflammatory drugs and in pernicious anemia hepatotherapy can be of great help in the healing of complicated phlebological cases.
Most leg ulcers are of venous or arterial origin (85%). Advanced chronic venous insufficiency is the most common underlying condition (65%), followed by advanced peripheral arterial occlusive disease (10%), and combined chronic venous insufficiency and peripheral arterial occlusive disease (10%). Chronic ulcers in diabetic feet (5%) are of great socio-economic importance, as well. They are a consequence of diabetic polyneuropathy which in part of the patients may be combined with peripheral arterial occlusive disease, usually of the calf arteries. However, a leg ulcer can also be caused by a large array of other underlying conditions, such as ulcerating skin tumours, trauma followed by disturbed wound healing, infectious ulcerations, ulcerations in angiodysplasias, vasculitic ulcerations, pyoderma gangrenosum, cholesterol-embolism, idiopathic livedo reticularis with ulceration, primary and secondary antiphospholipid-antibody-syndrome, coumarin-necrosis, calciphylaxis in chronic renal insufficiency, necrobiosis lipoidica, different forms of panniculitis, hematologic disorders, autoimmun diseases and autoimmun-bullous dermatoses. The following article discusses the differential diagnosis, examination and treatment of leg ulcers in these less common underlying conditions.
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