Cutaneous manifestations of diabetes mellitus: Correlation with HbA1C level—A cross-sectional observational study from a tertiary care center in Eastern India
Authors: Mandal Nirjhar , Praveen Pranjal , Sen Sumit , Banerjee Shayeri , Dey Pratik , Mandal Sudip 
Published: December 2023

Abstract

Background:
Diabetes mellitus (DM) is a common and debilitating endocrinological disease that affects a variety of organs, including the skin. Between 30% and 70% of patients with DM, both type 1 and type 2, will present with a cutaneous complication at some point during their lifetime. A variety of dermatologic manifestations have been linked with DM; these conditions vary in severity and can be benign, deforming, and even life-threatening. Such skin changes can offer insight into patients’ glycemic control and, indirectly, their HbA1C levels. It may be the first sign of metabolic derangement in undiagnosed patients with diabetes.

Objectives:
Statistically correlate HbA1C value with glycemic control using cutaneous manifestations of DM. To classify the severity of DM by taking into account certain cutaneous manifestations.

Materials and Methods:
Consecutive 103 diabetic patients attending dermatology outpatient department of a tertiary care hospital in Kolkata were included in the study. History regarding duration and type of DM, control of diabetes, and drug history were taken. Patients underwent thorough dermatological examinations to evaluate the skin disorder. Appropriate routine and laboratory investigations were done. Relevant microbiological and histopathological examinations were carried out in atypical and doubtful cases to confirm the diagnosis. Data were recorded and analyzed.

Results:
Out of 103 diabetic patients included in the study, 59 (57.3%) were male, and 44 (42.7%) were female, of which 89 patients had cutaneous manifestations associated with DM. We have noticed a significant correlation between certain types of skin manifestations and HbA1c values. The fungal infections were seen among mid (8.0–9.5) and low (6.5–8.0) HbA1c ranges. Most of the cases of xerosis and associated pruritus had HbA1c levels in the mid range. Vitiligo, nail changes, and systemic complications were mostly seen among HbA1c values in the mid and high range (9.5–11). In our study, there was a strong association of HbA1c value with the duration of diabetes (P = 0.001), diabetic dermopathy (P = 0.012), and systemic complications of DM (P = 0.027). Acanthosis nigricans (P = 0.016), nail changes (P = 0.041), and fungal infection (P = 0.032) also showed a significant association with HbA1c values. A statistically weak association was observed with bacterial infection (P = 0.362), xerosis (P = 0.487), lichen planus (P = 0.066), and vitiligo (P = 0.778).

Conclusion:
DM is the commonest endocrine disorder that frequently accompanies skin manifestation. Recognition of clinical features of DM is important as delayed detection is associated with comorbidities like coronary artery disease, hypertension, and dyslipidemia; until recently, dermatologists were of the opinion that diabetic ulcers were the only skin manifestation that predated its development but studies have shown that there are many more cutaneous manifestations specific to DM. These manifestations appear earlier than the systemic manifestations and, if recognized, can help in the early diagnosis of DM. Cutaneous manifestations can serve as a predictor for the long-term glycemic control of patients and help endocrinologists in preventing the grave complications of a silent killer like diabetes.

Limitations:
A small sample size compromised the external validity of the study. The study was conducted in a tertiary care center and was thus not representative of the situation in the field.