Patterns of dermatological disorders among

Diabetes Mellitus is a common metabolic disorder associated with significant dermatological alterations. This study was set out to demonstrate the pattern of the various dermatological disorders seen among diabetic population in Obafemi Awolowo University Teaching Hospitals Complex Ile Ife, a tertiary health care institution in south west Nigeria. Infective skin conditions appear to occur with greater frequency compared to the non-infective dermatoses and poor glycaemic control seems to be the most significant predictor of the presence of such skin lesions (p<0.001). Among diverse numbers of cutaneous lesions seen in this study, superficial fungal infections accounted for the highest prevalence and was seen in 35.4%. Pruritus ranked next with a prevalence of 16.7%. Others include Diabetic dermopathy (14.8%), acanthosis nigricans (4.9%), and Diabetic thick skin seen in 4% etc. The overall prevalence of cutaneous lesions in this study was 73%. Egyptian Dermatology Online Journal Vol. 9 No 2: 1, December 2013 2 http://www.edoj. org.eg Introduction Diabetes mellitus is the most common metabolic disorder of man that affects all socioeconomic strata and age groups. Frequency in the general population is between 2-6% while its incidence is known to be gradually increasing. [1] The disease affects approximately 60 million people globally. [2] However, between 1958 and 1993 the number of individuals diagnosed with diabetes mellitus increased fivefold. [3] It has been estimated by the World Health Organization (WHO) that the incidence will rise to 300 million by the year 2025. The rise in the prevalence of diabetes mellitus and other non-communicable diseases in Africa is due to increasing aging of the population and westernization of the life style. [4] Type 2 diabetes (T2DM) is the predominant form, yet, a classification problem persists for a proportion of patients. [5] [6] Interest in the skin manifestations of diabetic microangiopathy started in 1964 when Bauer et al [7] demonstrated periodic acid-schiff positive capillary basement membrane thickening (CBMT) in necrobiosis lipoidica diabeticorum (NLD) which was similar to the changes seen in diabetic microangiopathy in dermopathic lesion by Binkley [8] and in granuloma annulare. Other workers have also suggested that the underlying pathology of bullosis diabeticorum and rubeosis may be microangiopathy. [9] [10] [11] A relationship exists between diabetes mellitus and a series of cutaneous disorders. Diabetes mellitus related dermatoses usually occur when the underlying disease had already developed, however some skin disorders may herald or occur simultaneously with or even precede the underlying disease. [12] Some of these dermatoses (acanthosis nigricans, purpuric and pigmented capillaritis) are markers of macrovascular complications. These disorders including xerosis, dupytren's disease are also more frequently associated with microangiopathy in T2DM. Other skin diseases such as alopecia areata and vitiligo are markers of autoimmunity in type I diabetes. [13] At least 30% of diabetic patients have skin alterations which are related to diabetes mellitus, however some authors believe that the percentage may climb to 100% primarily due to the chronic nature of the disease. [14] [15] [16] In 1995, Onunu et al [17] studied the prevalence of cutaneous lesions among 250 diabetics and they put this at 63.2%. They found that the prevalence of cutaneous fungal infections, bacterial infections, foot ulcers, limb gangrene, amputated limbs and bullosis diabeticorum were significantly high in diabetic population. Necrobiosis lipoidica diabeticorum, diabetic dermopathy, insulin dystrophy, granuloma annulare, discoid lupus erythematosus were also seen. There are many skin disorders that are readily recognizable as markers of diabetes mellitus. Some of these disorders occur as a direct sequelae of diabetes mellitus or its major vascular complications, and neuropathy. Others are related to the impaired immunity seen in diabetes, whereas some occur as a consequence of the anti-diabetic treatment. Egyptian Dermatology Online Journal Vol. 9 No 2: 1, December 2013 3 http://www.edoj. org.eg Aims of the Work 1. To determine the prevalence and pattern of skin lesions among diabetic patients attending outpatient clinic at Obafemi Awolowo University Teaching Hospitals Complex Ile Ife, Nigeria. 2. To determine the proportion of different skin lesions associated with diabetes mellitus 3. To assess the relationship between the glycaemic control and the skin lesions. Materials and Methods This study is a cross sectional prospective study conducted at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. It is a tertiary care centre located in South West geopolitical zone of Nigeria. All consecutive DM patients attending the Medical outpatient department (MOPD) of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife who meet WHO 1999 diagnostic criteria for diabetes mellitus were recruited for the study. The study was carried out between November 2009 and May 2010( six months duration). Approval of the ethics and research committee of the hospital was sought and obtained before the study. Informed consent of the patient for the study was also obtained. The sample size was calculated based on documented 30% prevalence rate of cutaneous alteration among diabetics. [14] [15] [16] A total of three hundred and fifty eight(358) patients were then recruited for the study. The patients were diagnosed to be diabetic clinically and confirmed using WHO diagnostic criteria. They include the following: Fasting plasma glucose >7.0mmol/l (126mg/dl) or random plasma glucose >11.1mmol/l (200mg/dl). One abnormal laboratory value was diagnostic in symptomatic individuals, while two values were needed in asymptomatic people. The glucose tolerance test was only required for borderline cases and for gestational diabetes. Data were obtained from the patients using proforma that included demographic data such as age, sex, occupation and educational qualification. Date of the diagnosis of diabetes was obtained and the duration of diabetes was noted. Family history of diabetes was sought for and the type of treatment used for blood glucose control was obtained. Thorough physical examination, during which the whole skin was examined in bright light for any abnormality was carried out. Hand lens/magnifying glass was used where appropriate to make small tiny vascular changes, small scales and skin markings more obvious. The weight of each patient was obtained using a weighing scale and the height was obtained using a stadiometer. The Body Mass Index (BMI) was calculated using weight/height [2]. BMI of 18.524.9 was considered normal, <18.5 was considered underweight, 2529.9 was considered as overweight while >30 was considered obese. The patients did the following investigations, full blood count, urinalysis, Fasting Blood Sugar Egyptian Dermatology Online Journal Vol. 9 No 2: 1, December 2013 4 http://www.edoj. org.eg (FBS) + Two Hours Post Prandial (2HPP), serum electrolytes, urea and creatinine, lipid profile. Skin scrapings were done for patients with clinical diagnosis of fungal infections using sterile surgical blades, and scrapings wrapped with clean dry labeled white papers and taken to the laboratory. Mycological studies were done, and this involved placing drops of potassium hydroxide on clean flamed slides, placing small amounts of scrapped skin specimens on the slides and covering with cover slips. The samples were allowed to stand for ten minutes and thereafter examined under the microscope for fungal elements. Skin biopsy for histology was also done for confirmation when indicated. Glycated hemoglobin level was measured for one out of every three patients (120 patients) due to economic consideration and the mean blood glucose records over 3 months period was used to assess the glycaemic control for all the patients. The mean fasting and two hours postprandial blood glucose was calculated from the average of three monthly retrospective fourth nightly or monthly documented blood glucose check. Mean FBS and 2HPP less than 7mmol/l and 10mmol/l respectively were considered as a good glycaemic control, while values greater than 7mmol/l and/or 10mmol/l respectively were considered as a poor glycaemic control. Also glycated haemoglobin percentage less than 7% was taken as good control while values greater than 7% was taken as poor glycaemic control. Data were analyzed using a statistical computer soft ware SPSS 16.0 (Statistical Package for the Social Sciences, version 16.0). Data were represented using descriptive statistics such as tables, and charts. P value of less than 0.05 was used as level of significance.