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Original Paper
Med Princ Pract 2006;15:427430
DOI: 10.1159/000095488
Cutaneous Manifestations of Diabetes
Mellitus
Study from Farwaniya Hospital, Kuwait
Nawaf Al-Mutairi Amr Zaki Ashok Kumar Sharma Mazen Al-Sheltawi
Department of Dermatology, Farwaniya Hospital, Kuwait

Introduction
Diabetes mellitus (DM) is the most common endo-
crine disorder [1] . The cutaneous manifestations of DM
are well known and considered as common, as observed
in 3071% of diabetic patients [1, 2] . The exact pathogen-
esis of most of these dermatoses is unknown. It is reason-
able to assume that vessel and connective tissue altera-
tions as well as the impairment of the immune system
and other associated metabolic changes caused by diabe-
tes play an important role. DM is common in Kuwait;
about 15% of the adult Kuwaiti population has type 2 di-
abetes [3] and the prevalence of type 1 diabetes is 269.9
per 100,000 Kuwaiti children [4] . Although diabetes is
common in Kuwait, systematic surveys of the cutaneous
manifestations in diabetic patients are lacking. Therefore
the aim of our study was to evaluate the frequency of skin
manifestations in these patients with diabetes.
Subjects and Methods
The study was conducted in the Department of Dermatology,
Al-Farwaniya Hospital, Kuwait. The protocol for this study was
approved by the hospitals Ethics Committee. All diabetic patients
attending the Dermatology Out-Patient Clinic and diabetic in-
patients with skin problems were examined over a period of 18
months from March 2004 to August 2005. A diagnosis of diabetes
was made using uniform criteria: symptoms of diabetes plus ran-
dom blood glucose concentration 6 11.1 mmol/l (200 mg/dl) or
fasting plasma glucose 6 7.0 mmol/l (126 mg/dl) or 2-hour plasma
Key Words
Diabetes mellitus Cutaneous manifestations
Abstract
Objective: To study the prevalence of cutaneous disorders
in patients with diabetes mellitus. Subjects and Methods:
All diabetic patients attending the Department of Dermatol-
ogy, Al-Farwaniya Hospital, Kuwait, and diabetic in-patients
with skin disorders were examined over a period of 18
months from March 2004 to August 2005. A total of 106 dia-
betic patients displaying 1 or more dermatological manifes-
tations were identified and thoroughly examined for any
skin disorder. The diabetic profile of the patients was ob-
tained from medical records. Results: Of the 106 patients, 69
had only 1 cutaneous manifestation, 27 had 2, 6 had 3 and 4
had 4. Infections (68.0%) were the major cutaneous manifes-
tations with fungal infection occurring in 41 patients fol-
lowed by bacteria in 27. The second most common present-
ing symptom was pruritus. Hypertension (74%) was the most
common systemic complication, and most of the diabetic
patients who developed cutaneous manifestations were in
the 40- to 60-year age group. Conclusions: The data show
that infections were the most common cutaneous manifes-
tation and hypertension the most common systemic compli-
cation. Copyright 2006 S. Karger AG, Basel
Received: September 13, 2005
Revised: January 24, 2006
Dr. Nawaf Al-Mutairi
PO Box 280
Farwaniya (Kuwait)
Tel. +965 937 0203, Fax +965 480 8167
E-Mail [email protected]
2006 S. Karger AG, Basel
10117571/06/01560427$23.50/0
Accessible online at:
www.karger.com/mpp
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Med Princ Pract 2006;15:427430 428
glucose 6 11.1 mmol/l (200 mg/dl) during an oral glucose toler-
ance test. In the absence of unequivocal hyperglycaemia and acute
metabolic decompensation, these criteria were confirmed by re-
peat testing on a different day. Informed consent was obtained
from the patients. The patients who were diagnosed as having DM
following investigation of dermatological manifestations were
also included in the study. Each subject underwent a thorough
dermatological examination.
A working classification of cutaneous manifestations of DM
into four groups was adopted [1] , and an attempt was made to
place the observed skin lesions into one of these four categories:
(a) cutaneous conditions with strong associations with DM;
(b) skin manifestations related to infectious origins; (c) skin man-
ifestations related to complications of DM, and (d) skin lesions
related to treatment of DM. Medical records of these patients were
reviewed for information regarding duration of diabetes, daily
medications, complications of diabetes such as retinopathy and
neuropathy, fasting triglycerides, cholesterol levels and renal
function. Relevant microbiological and histopathological investi-
gations were carried out to confirm the clinical diagnosis on all
the patients with cutaneous manifestations.
Results
The general profile of the patients is given in table 1 .
Of the 106 patients, the majority (42.5%) were between
40 and 60 years of age. Among patients presenting with
skin complaints, there were more type 2 diabetics (93 pa-
tients) than type 1 (13). Of the 106 patients, 88 (83%) were
known diabetics and 18 (17%) were diagnosed as diabet-
ics in the skin Out-Patient Department after investiga-
tion. Fifty-nine of the 88 patients have diabetes of over a
10-year duration.
Cutaneous manifestations according to the four
groups are given in table 2 . Pruritus was the most com-
mon in 52 patients, followed by fungal (41) and bacterial
(27) infections. Sixty-nine patients (65%) had only 1
manifestation, 27 (25.5%) had 2, 6 (5.7%) had 3 and 4
(3.8%) had 4. Types of fungal, bacterial and viral infec-
tions are given in table 3 . Tinea pedis was the most com-
mon fungal infection while folliculitis was the most
common bacterial infection. Three patients had recur-
rent herpes simplex. Cutaneous infections were found to
be more common during the first 5 years of diabetes (46
Table 1. General profile of 106 diabetic
patients
Parameter Observations
Sex distribution
Male:female 68:38
Total 106
Age distribution of patients
>020 years 5 (4.7%)
>2040 years 33 (31.1%)
>4060 years 45 (42.5%)
>6080 years 23 (21.7%)
Total 106
Type of diabetes
Type 1 13
Type 2 93
Total 106
Duration of diabetes
<5 years 22
>510 years 25
>10 years 59
Total 106
Table 2. Cutaneous manifestations of DM in the patients
Cutaneous manifestations Cases Percentage
Cutaneous conditions with strong associations with DM
Diabetic dermopathy 6 5.7
Diabetic thick skin 1 1
Necrobiosis lipoidica 1 1
Rubeosis faciei 11 10.4
Acanthosis nigricans 5 4.7
Diabetic bullae 2 1.9
Xanthomas 7 6.6
Scleredema adultorum 1 1
Pruritus 52 49
Acrochordons 11 10.4
Vitiligo 3 2.8
Granuloma annulare 2 2
Lichen planus 5 4.7
Acquired perforating dermatoses 2 2
Total 109
Cutaneous conditions related to infectious origins
Fungal 41 38.7
Bacterial 27 25.5
Viral 3 3
Total 71
Cutaneous conditions related to complications of DM
Diabetic neuropathy 10 9.4
Diabetic ulcer 2 2
Total 12
Cutaneous conditions related to treatment of DM
Sulphonylurea-related skin lesions 3 3
Insulin lipo-atrophy 3 3
Insulin-allergic reactions 1 1
Total 7
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Cutaneous Manifestations of Diabetes
Mellitus
Med Princ Pract 2006;15:427430 429
patients). Of the 7 patients with xanthomas, 3 had an
eruptive variant and in addition had hypertriglyceridae-
mia.
The systemic complications and associations of DM
with cutaneous manifestations are shown in table 4 .
Many of the patients had more than 1 underlying sys-
temic complication. Hypertension was observed in 44 pa-
tients.
Discussion
Similar to a previous study [5] , male patients outnum-
bered female patients ( table 1 ) in our study, but not in
another study [6] in which there were more female pa-
tients.
The majority of our patients were in the 40- to 60-year
age group, an observation also noted by other researchers
[5, 6] . The relative increase in the incidence of cutaneous
involvement with age in diabetic patients may be attrib-
uted merely to the long duration of diabetes in these pa-
tients.
The majority of patients in this study had type 2 DM,
as has been noted in other studies [5, 6] , apparently re-
flecting the general distribution pattern of type 1 and
type 2 DM cases in world populations [1, 5] . No difference
in the prevalence of cutaneous disorders between type 1
and type 2 DM patients has been noted [1, 5] .
Among the cutaneous disorders observed in our DM
patients, infections comprised the largest group affecting
67% of the cases, similar to previous reports [5, 6] . It is
well known that diabetic patients are susceptible to infec-
tions probably due to hyperglycaemia and defects in poly-
morphonuclear leucocyte function [7] . Surprisingly, viral
infections in diabetic patients have not been reported in
previous studies as observed in our study where 3 dia-
betic patients showed recurrent herpes simplex. It is dif-
ficult to say whether it is an incidental observation or
whether compromised resistance of the diabetic state is
somehow responsible for precipitating the recurrences.
Pruritus was the second most common manifestation
among our diabetic patients and was seen in 49% of pa-
tients in the present study. Similar observations have
been reported [6] , including a review that questions the
relationship between generalized itching and DM [8] .
However, we believe that generalized itching, at least in
some DM cases, cannot be readily explained by any oth-
er cause except by the underlying DM.
The 5.7% of patients with diabetic dermopathy ob-
served in this study falls within the range of previous re-
ports of 3.59.37% [5, 6] . While a comprehensive review
on the subject considers diabetic dermopathy to be the
most common manifestation in DM [1] , we did not ob-
serve it to be so common.
Table 3. Type of infection seen among diabetic patients
Type of infection Cases Percentage
Fungal infections
Tinea corporis 5 7
Tinea cruris 4 5.6
Tinea pedis 15 21
Tinea unguium 2 2.8
Paronychia 3 4.2
Candidal vulvovaginitis 7 9.9
Candidal balanoposthitis 1 1.4
Candidal intertrigo 4 5.6
Subtotal 41 57.7
Bacterial infections
Folliculitis 14 19.7
Impetigo (bullous) 2 2.8
Furunculosis 1 1.4
Carbuncle 2 2.8
Cellulitis 4 5.6
Infectious eczematoid dermatitis 1 1.4
Erythrasma 3 4.2
Subtotal 27 38
Viral infections
Herpes simplex 3 4.2
Subtotal 3 4.2
Table 4. Diabetic complications/associa-
tions in 61 patients
Complications Cases
Retinopathy 7
Nephropathy 2
Neuropathy 18
Hyperlipidemias 10
Hypertension 44
Coronary artery disease 4
Peripheral vascular disease 3
Total 88
The total number exceeds the num-
ber of patients (61) because many showed
more than 1 complication/association.
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Med Princ Pract 2006;15:427430 430
The 1% of patients with necrobiosis lipoidica observed
in this study is similar to that reported by Nigam and
Pande [5] although Mahajan et al. [6] did not make a
similar observation. It is generally well known that nec-
robiosis lipoidica is not common in diabetic patients with
a reported incidence of 0.31.6% [1] . Dermatoses associ-
ated with an increased incidence of DM, like vitiligo,
lichen planus and acquired perforating dermatoses de-
tected in the present study, have been reported previ-
ously [1] .
An attempt was made to note the underlying systemic
complications attributed to DM in our patients. Hyper-
tension (44 patients) was identified as the one systemic
feature most common in our diabetic patients showing
cutaneous involvement consistent with the previous re-
port of Mahajan et al. [6] which also included retinopathy
among others. Hypertension has been hypothesized to
accelerate the process of micro-angiopathy in diabetics
[6].
Conclusion
Most of the diabetic patients who developed cutaneous
manifestations were in the 40- to 60-year age group, and
infections were the single largest type of involvement
while the most common systemic complication of diabe-
tes was hypertension.
References
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patients and their association with diabetes
risk factors and microvascular complica-
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3 Akanji AO: Diabetic dyslipidaemia in Ku-
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4 Moussa MA, Alsaeid M, Abdella N, Refai
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waiti children. Med Princ Pract 2005;14:87
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5 Nigam PK, Pande S: Pattern of dermatoses in
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6 Mahajan S, Koranne RV, Sharma SK: Cuta-
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