Jurnal DM Kulit 3
Jurnal DM Kulit 3
Jurnal DM Kulit 3
Article history: Introduction: Diabetes mellitus (DM) is the common endocrine disorder, which affects all ages and
Received 27-05-2020 socioeconomic groups. The prolonged hyperglycemia may responsible for the diabetic complications.
Accepted 04-06-2020 Multiple factors contribute to the onset of cutaneous manifestations in diabetes mellitus. The present study
Available online 25-06-2020 aimed to study the pattern of various cutaneous manifestations associated with diabetes mellitus.
Materials and Methods: The present study was conducted at Dermatology, Diabetic Clinic of a teaching
tertiary care centre hospital. A total of 120 subjects were included in this study. Patients were selected
Keywords: on the basis of dermatological signs and/or symptoms. Detailed history and clinical examination with
Acrochordons
special emphasis on dermatological complaints and signs was done for all the study subjects. Under aseptic
Cutaneous manifestations
conditions, blood samples were collected and used for the estimation of blood glucose, bacterial infections-
Dermatoses Gram stain and isolation of organism by culture, fungal infections- KOH (potassium hydroxide) mount,
Gram stain (for Candida) and isolation of organism by culture. Skin biopsies were performed wherever
necessary.
Results: In the present study, 120 subjects were included from both genders. Pruritus was the predominant
symptom observed. Acrochordons, Candidial Balanoposthitis, Tinea Corporis were observed in highest
number of patients. Infective dermatoses were observed in 72 (60%) patients. The non-infective dermatoses
was reported in 56 (46.7%) patients. On bacterial culture, Pyogenic Ulcer was observed in 4. KOH test and
culture were carried on 14 candidal infections and 17 dermatophyte infection and observed KOH mount
positive were observed in 11 cases and culture positive was observed in 8 cases.
Conclusion: In the present study results indicates pruritus was the most common symptom in diabetic
subjects. Infective dermatoses were more common than the non-infective dermatoses. Tinea corporis/cruris
was most common clinical entity. 21.6% patients suffered from cutaneous bacterial infections, the most
frequently encountered clinical entity being furunculosis. Staphylococcus aureus The commonest non-
infective clinical entity was acrochordons (skin tags). Patients with diabetes may develop cutaneous
manifestations of diabetic complications. Careful dermatological examination and follow-up of diabetes
mellitus patients is required to provide them adequate skin management.
© 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license
(https://creativecommons.org/licenses/by-nc/4.0/)
https://doi.org/10.18231/j.ijced.2020.028
2581-4710/© 2020 Innovative Publication, All rights reserved. 136
Bose and Kumar / IP Indian Journal of Clinical and Experimental Dermatology 2020;6(2):136–144 137
such as macrovascular and microvascular complications. 4 signs was done for all the study subjects. Under aseptic
Globally, the prevalence of skin disorders in diabetes conditions, blood samples were collected and used for the
mellitus may veries from 51.1% to 97%. 5 estimation of blood glucose, bacterial infections- Gram stain
Multiple factors contributes to the onset of cutaneous and isolation of organism by culture, fungal infections-
manifestations in diabetes mellitus, which include abnormal KOH (potassium hydroxide) mount, Gram stain (for
carbohydrate metabolism, altered metabolic pathways, vas- Candida) and isolation of organism by culture. Generalized
cular abnormalities such as microangiopathy, atherosclero- pruritus- CBC (complete blood count), LFTs (liver function
sis, neuronal degeneration, and impaired host mechanisms. 6 tests), and RFTs (renal function tests) were done. Skin
The dermatological manifestations in diabetes mellitus may biopsies were performed wherever necessary, and formalin
vary from minor to lifethreatening. 7 fixed paraffin embedded sections of the sampled tissues
Dermatological manifestations of diabetes mellitus can were stained with hematoxylin and eosin and observed
be broadly categorized into four groups; skin lesions under light microscope.
strongly associated with diabetes, skin lesions of infectious
etiology, lesions secondary to complications of diabetes and 3. Results
lesions related to diabetic treatment. 1
The most common cutaneous infections, staphylococcal In the present study, 120 subjects were included from both
infections, are more perilous and severe in patients with genders. Majority of the subjects were from 51-60 years of
uncontrolled diabetes. Other types of infection include styes age group. Out of 120 patients, 116 were type 2 diabetcs and
that cause tuberculosis of eyelid and also bacterial infection 4 were type 1 diabetics. Duration of diabetes, 87 (72.5%)
of the nails. A fungus called Candida albicans is involved patients were ≤5 years and 33 (27.5%) were ≥5 years. In
in the numerous fungal infections in diabetic patients and the present study, pruritus was the predominant symptom
these are common in vaginal area and lips corners (angular observed followed by Cosmetic Concern as represented in
cheilitis). 8 Table 1. Acrochordons, Candidial Balanoposthitis, Tinea
In addition, skin disorders commonly associated with Corporis were observed in highest number of patients. The
diabetes, which as diabetic dermopathy, necrobiosis distribution of dermatoses in this study was represented in
lipoidica, diabetic bullae, diabetic thick skin, yellow skin, Table 2 and Figures 1, 2, 3, 4, 5, 6 and 7.
acanthosis nigricans, eruptive xanthomas, disseminated
Table 1: Predominant sympoms in the diabetes mellitus subjects
granuloma annulare, scleredema, yellow nails, skin tags,
diabetic rubeosis, vitiligo and lichen planus. 1 Commonly Predominant Symptoms No. of Patients
seen cutaneous bacterial infections in diabetes mellitus are Asymptomatic 2(1.7%)
folliculitis, furunculosis, carbuncle, ecthyma, cellulitis and Cosmetic Concern 33(27.5%)
Pain 21(17.5%)
erysipelas. Other associated disorders are calciphylaxis,
Pruritus 50(41.6%)
xerosis, xanthelasma, lipodystrophy, macular amyloidosis
Soreness 21(17.5%)
and alopecia. 9 Commonly seen viral infections include Other 4(3.3%)
herpes zoster and viral warts. 10 Total 131
Hence, the good knowledge about dermatological
*11(9.1%)Patients Had 2 Predominant Symptoms Each
manifestations of diabetes mellitus may be helpful in the
overall prognosis improvement of disease through the early
diagnosis and treatment. 11 The present study aimed to study In the present study, infective dermatoses was observed
the pattern of various cutaneous manifestations associated in 72 (60%) patients. In this, cutaneous fungal infections
with diabetes mellitus. were observed in 46 (38.3%) and cutaneous bacterial
infectious were observed in 26 (21.7%) patients. The non-
infective dermatoses was reported in 56 (46.7%) patients
2. Material and Methods
as reported in Table 3. The distribution of cutaneous
The present study was conducted at Dermatology, Diabetic bacterial Infections and their microbiological aspects were
Clinic of a teaching tertiary care centre hospital. After represented in Table 4. On bacterial culture, Pyogenic
approval from Institutional Ethics Committee and informed Ulcer was observed in 4, Furunculosis in 3, Ecythema in
consent from study subjects, a total of 120 subjects 2, Pyogenic Abscess in 2, Folliculitis and Carbuncle 1
were included in this study. Out of 120 subjects, 68 in each as represented in Table 5. In the present study,
were males and 52 were females. Subjects below 12 to study the cutaneous fungal infections, KOH test and
years of age, those with impaired glucose tolerance, culture were carried on 14 candidal infections and 17
gestational diabetic subjects were excluded from the study. dermatophyte infection. It was observed that KOH mount
Patients were selected on the basis of dermatological signs positive was observed in 11 cases and culture positive
and/orsymptoms. Detailed history and clinical examination was observed in 8 cases as reported in Table 6. On
with special emphasis on dermatological complaints and culture, Trichophyton Rubrum observed in 7 cases and
138 Bose and Kumar / IP Indian Journal of Clinical and Experimental Dermatology 2020;6(2):136–144
Fig. 3: DiabeticDermopathy
4. Discussion
Skin manifestations are commonly seen in diabetes mellitus
patients as result of changes in the metabolism such as
hyperglycemia, or damage to vascular, neurological or
immune system. 12 Infections increases the possibility of
developing neurovascular and other systemic complications
which can give rise to various dermatological manifesta-
tions. 13
In the present study, 116 (96.7%) were type 2 diabetes
Fig. 6: Xanthelasma
mellitus and 4 (3.3%) were type a diabetes. In a study by
Nigam PK et al reported that 82.1% of subjects had type 2
diabetes. 14 and Mahajan S et al reported that 98% cases had
type 2 diabetes mellitus. 15
Patients in whom the diabetic status was detected within
past five years are called ’early diabetics’ as against ’chronic
diabetics’ in whom the diabetic status was detected more
than 5 years back. 16 In our study, majority (72.5%) of
patients (n= 87) were early diabetics.
The duration of diabetes varied widely among our
study population. 9 (7.5%) of our patients presented with
dermatological complains in the OPD, and on clinical
suspicion were subjected to fasting and post-prandial blood
sugar level estimation, and thereby their hitherto undetected
diabetic status was revealed, The remaining 111 (92.5%)
patients were already known sufferers of diabetes mellitus.
The duration of diabetes in patients in the study by Nigam
PK et al, 14 varied from 2 months to 27 years with a mean
of 66.4 months. In the study by Rao GS et al., 71 (80.7%)
Fig. 7: Vitiligo patients were known diabetics, and 17 (19.3%) patients were
diagnosed to have hitherto undiagnosed diabetes in the skin
140 Bose and Kumar / IP Indian Journal of Clinical and Experimental Dermatology 2020;6(2):136–144
Table 4: Distribution of cutaneous bacterial Infections and their microbiological aspects in the study subjects
No. of Sampled for Gram Stain No of cases
Clinical Entity microscopy with growth
Patients + Organism - Organism No Results
Furunculosis 8 and
5 culture 3 - 2 on
3 culture
Pyogenic Ulcer 4 4 3 - 1 4
Ecthyma 3 2 2 - - 2
Folliculitis 3 2 2 - - 1
Pyogenic Abscess 3 2 2 - - 2
Erysipelas 2 - - - - -
Carbuncle 1 1 1 - - 1
Cellulitis 1 - - - - -
Erythrasma 1 - - - - -
Total 26 16 13 - 3 13
Table 6: Distributionof cutaneous fungal infection in the study population and their Mycological Aspects
Clinical Entity No. of Sample for KOH Mount Positive Positive For Culture
Patients microscopy and
culture
Candidal Infections
Balanoposthitits 12 8 5 3
Vulvovaginitis 5 2 1 1
Paronychia 4 3 - 1
Intertrigo 1 1 - -
Total 22 14 6 5
Dermatophyte infection
Tinea Corporis 12 8 6 4
Tinea Pedis 5 4 2 2
Tinea Manum 1 1 1 1
Tinea Unguium 6 4 2 1
Total 24 17 11 8
OPD after proper investigation. 16 Of the total 120 patients, 8 (6.7%) patients had 2
Pruritus causes excoriations on the skin which increases dermatological conditions each. Remaining 112 (93.3%)
the risk of developing of infections. Generalized pruritus patients presented with only one dermatological condition
may be seen secondary to complications such as xerosis, each. Among 88 diabetic patients studied by Rao GS et
chronic renal insufficiency, and diabetic polyneuropathy. al, 66 (75%) had only one cutaneous manifestation, 16
Certain antidiabetic drugs and dry skin which is aggravated (18.18%) patients had two, 4 (4.55%) had three and 2
by age and reduced sweating secondary to diabetic (2.27%) had four cutaneous manifestations each. 16
autonomic neuropathy have also been implicated in the Acrochordons (skin tags), candidal balanoposthitis, and
pathogenesis of diabetic pruritus. 17 tinea corporis /cruris with 12 (10%) patients each, were
Pruritus was the most common symptom in our study the leading dermatoses as a single clinical entity. There
with 50 (41.6%) of patients presenting with pruritus as were 9 (7.5%) cases of lichen planus, 8 (6.7%) cases
the predominant complaint. 33 (27.5%) patients sought each of furunculosis and generalized pruritus without skin
dermatological advice primarily for cosmetic concern of lesions, and 7 (5.8%) cases of vitiligo. There were 6
their skin lesions. Pain and soreness observed in 21 (17.5%) (5%) cases of onychomycosis; 5 (4.2%) cases each of
patients each were prominent symptoms in most of the candidal vulvovaginitis, and xanthelasmas; 4 (3.33%) cases
remaining patients. In 11 (9.1%) of patients, soreness and each of acanthosis nigricans, candidal paronychia, and
pruritus were equally distressing to the patient. Rao GS pyogenic ulcer. We observed 3 (2.5%) cases each of diabetic
et al., also found that pruritus was the main presenting neuropathy, ecthyma, folliculitis, perforating disorders and
symptom and was noted in 60.2% of their patients. 16 pyogenic abscesses. There were 2 (1.7%) cases each of
Al-Mutairi et al reported on the prevalence of cutaneous diabetic dermopathy (shin spots), erysipelas, and bullosis
manifestations in 106 patients with diabetes mellitus: diabeticorum. We encountered only 1 (0.8%) case each
pruritus was shown to be the second most common of candidal intertrigo, carbuncle, cellulitis, necrobiosis
cutaneous manifestation. 18 lipoidica diabeticorum and erythrasma.
In a single center epidemiologic study conducted in Galdeano et al. conducted a study on 125 diabetic
Iran, infection was also the most common lesion reported patients in a single center in Argentina. Reported a
by patients in this study, the most common noninfectious high prevalence of skin disorders: 90.4%. Skin disorders
manifestation was pruritus. 1 Similarly, Sasmaz et al. occurring in more than 10% of the patients included
showed that most common skin conditions in DM patients xeroderma (69%), dermatophytosis (52%), onychomycosis.
are infections (31.7%), non-candidal intertrigo (20.5%), (49%), tineapedis (39%), peripheral hypotrichia (39%),
eczemas (15.2%), psoriasis (11.2%), diabetic dermopathy diabetic dermopathy (35%) skin thickening syndrome
(11.2%), and prurigo (9.9%). 19 (25%), diabetic foot (24%), candidiasis (17%), fibroids
142 Bose and Kumar / IP Indian Journal of Clinical and Experimental Dermatology 2020;6(2):136–144
pendulums (11%), intertrigo (10%), and inner eyebrow On direct microscopy of the collected sample, on 13
separation (10%). 20 (yield is 13/16 = 81.3%) occasions, Gram positive bacteria
A study conducted by Foss NT in Brazil, demonstrated could be identified. On three occasions, neither Gram
that 81% of patients had at least one dermatologic lesion, positive nor Gram negative bacteria could be seen. Of
with a mean of 3.7 lesions/patient, being dermatophytosis the 16 samples plated for culture, pathogenic bacteria
the most common lesion. Of all dermatophytosis, 42.6% could be isolated on 13 (yield is 13/16 = 81.3%)
were onychomycoses (n = 172) and 29.2% were tinea pedis occasions. Staphylococcus aureus was the most frequently
(n = 118). Skin lesions occurring in > 10% of the patients (61.5%) isolated bacterium (n=8), followed by ’Group
were actinic degeneration (62%), skin xerosis (20.8%), A beta hemolytic strepotococci’ (Streptococcus pyogenes)
benign skin tumor (23.5%), candidiasis (12.9%) and scar which was isolated on 4 occasions including once with
(12.6%). 21 Staphylococcus aureus (mixed infection). In the study by
In our study the infective dermatoses were more common Nigam PK et al, 14 Staphylococcus aureus was the most
than the non-infective dermatoses. Total of 72 (60%) frequently isolated bacterium (65.6%), and Streptococcus
patients suffered form either a cutaneous bacterial or pyogenes was isolated on 12.5% occasions.
fungal infection, of which 63.9% (n= 46) had cutaneous In our study, in one case of pyogenic ulcer on foot,
fungal infections. These 46 patients with cutaneous fungal the culture yielded two Gram negative bacteria- Citrobacter
infections contributed to more than one third (38.3%) of and Acenetobacter (Gram negative bacteria could not be
entire study population. Cutaneous bacterial infections were demonstrated on direct microscopy).
seen in about one fifth (n=26) of the study population. The Out of total 46 cases of cutaneous fungal infections
ratio of cutaneous fungal infections to bacterial infections in observed in our study, there were 24 (52.2%) patients
our study was 1.77:1 56 (46.6%) of our patients presented with dermatophyte infections of skin and /or nails and 22
with non-infective dermatoses. (47.8%) patients with muco-cutaneous candidal infections.
Infections comprised the largest group affecting 35 of Nigam PK et al 14 , observed 21 diabetics with cutaneous
64 (54.7%) cases in the study by Mahajan S et al 15 the fungal infections-13 (61.9%) with dermatophyte skin/nail
ratio of cutaneous fungal to bacterial infections being 1.5:1. infections and 8 (38.1%) with mucocutaneous candidalin-
Gulati et al 22 reported cutaneous infections in 49% of their fections. Similarly, the dermatophyte infections (11 cases)
study population of diabetics. Similarly Rao GS et al 16 were slightly more common than the mucocutaneous
reported even higher rates of cutaneous infections in their candidal infections (10 cases) in the study by Mahajan S et
diabetic patients (78.4%) with 59.4% of their total cases al. 15 Thus the ratios of dermatophyte to candidal infections
been suffered from cutaneous fungal infections. The ratio in ours, Nigam’s and Mahajan’s study were 1.1:1,1.6:1, and
of cutaneous fungal to bacterial infection in their study was 1.1:1 respectively.
1.64:1. In the study by Nigam PK et al, 14 the cutaneous In our study, among mucocutaneous candidal infections,
bacterial and fungal infections formed the largest group balanoposthitis was the most common clinical entity
with 32 (26.2%) cases and 21 (17.2%) cases respectively with 12 (54.5%) cases, followed by 5 (22.7%) cases of
contributing to a total of 43.4% of all dermatoses observed. vulvovaginitis. However, Mahajan S et al 15 observed that
However, the ratio of cutaneous fungal to bacterial infection vulvovaginitis with 5 cases was most common entity among
in their study was 0.65:1. 10 of their cases with muco-cutaneous candidal infections.
Among 26 patients with cutaneous bacterial infections in In our study, 4 (18.2%) patients had chronic paronychia and
our study, the most frequently encountered clinical entity 1(4.5%) had intertrigo.
was furunculosis with 8 patients, contributing 30.8% of In our study, in only 6 (yield= 42.8%) of 14 cases
all bacterial infection cases, followed by pyogenic ulcers sampled, the organism could be seen on KOH mount. On 5
with 4 (15.4%) cases. In the study by Nigam PK et (yield= 35.7%) occasions, positive growth of the organism
al, 14 there were 32 (26.2%) patients who suffered from was obtained, Candida albicans being the only species
cutaneous bacterial infections, the most common clinical isolated in all these cases and 3 of these 5 cases were of
entity been furunculosis (15 eases) followed by folliculitis balanoposthitis.
(8 cases). In the study by Mahajan S et al 16 , 12 (18.7%) In our study, there were 24 (52.2%) patients with
patients had cutaneous bacterial infections, the commonest dermatophyte infections of skin and/or nails. Of these, 12
clinical entity been folliculitis (7 cases). In our study, (50%) had either tinea corporis and /or cruris (tinea cruris
there were 3 (11.5%) cases each of ecthyma, folliculitis, and corporis= 7, only tinea cruris= 3, only tinea corporis=
andpyogenic abscesses. We also encountered two (7.7%) 2 including one with tinea incognito), 5 (20.8%) had tinea
cases of erysipelas, and one (3.8%) case each of carbuncle, pedis and one (4.2%) had tinea manuum. 6 (25%) patients
cellulites, and erythrasma. presented with dermatophyte infections of the nails (tinea
Of these 26 cases of bacterial infections, pus/exudate unguium) of which 3 had only nail infection and remaining
samples of 16 cases were sent for Gram stain and culture. 3 had concomitant skin infection (tinea pedis= 2, tinea
Bose and Kumar / IP Indian Journal of Clinical and Experimental Dermatology 2020;6(2):136–144 143
manuum= 1). In their study, Nigam PK et al, found 10 be demonstrated, and relevant investigations performed (as
(76.9%) patients with tinea corporis/cruris and 3 (23.1%) mentioned in methodology) to detect underlying systemic
patients with tinea unguium of the total 13 patients with cause if any for the unexplained pruritus were within normal
dermatophyte infections. Among dermatophyte infections limits. There were 9(7.37%) patients in the study by Nigam
observed by Mahajan S et al, 15 6 (54.5%) cases were of PK et al, 14 who had generalized pruritus with out any
cutaneous infection and 5 (45.5%) were of tinea unguium. demonstrable skin lesion, and the authors attributed it to the
In our study, out of the 17 cases of dermatophyte hyperglycemic status of their patients.
infections which were sampled for microscopy and culture, The occurrence of cutaneous infections in early diabetics
on KOH mount, fungal hyphae could be seen in 11 (yield= may be explained on the basis of decrease in the
64.7%) cases and positive growth of dermatophyte species host defense mechanism and decreased phagocyte activity
was observed on culture on 8 (yield= 47.1%) occasions. which is noticed immediately in uncontrolled diabetes
These included 4 cases of tinea corporis/cruris, 2 cases of and these changes do not require much longer time to
tinea pedis, and one case each of tinea manuum and tinea develop unlike microangiopathy. 23 Skin manifestations due
unguium. The dermatophytic species identified in all cases to diabetic microangiopathy areseen more commonly in
was Trichophyton rubrum (87.5%), except for growth of chronic diabetes because the deposition of PAS-positive
Trichophyton mentagrophytes from one case of tinea pedis. material (advanced glycosylation end products) within the
Co-infection of two or more species was not observed in any lumina of theblood vessels occurs slowly in the disease
of our cases. In the study by Nigam PK et al, 14 Trichophyton process. 24
rubrum was the most commonly isolated species on culture,
identified on 11 (84.6%) of 13 occasions. In our study, a Of the total 120 patients, 98 (81.7%) patients were
total of 56 (46.7%) patients presented with non-infective only on oral hypoglycemic agents (OHAs). 7 (5.8%)
dermatoses associated with diabetes mellitus. All patients patients (including 4 patients of type 1 DM) were only on
had one cutaneous manifestations each except for 3 (2.5%) insulin (daily subcutaneous injections), and 6 (5%) patients
cases in which two unrelated cutaneous manifestations required both insulin and OHAs to control there blood
existed concomitantly in the same patient. sugar levels. 9(7.5%) patients who were diagnosed to have
The commonest clinical entity was acrochordons (skin diabetes after presenting to dermatological OPD, were yet
tags) with 12 cases contributing to 21.4% of cases of this to be started on any anti-diabetic medication at the point
group and 10% of total study population. This was closely ofinclusion in the study. We did not encounter any patient
followed by lichen planus (LP) with 9 (16.1%) cases-4 with cutaneous adverse reaction to either OHA or insulin in
eruptive LP, 3 oral LP, 2 cases of lichen planopilaris (with our study. These findings were supported by Nigam PK et al
co-existent eruptiveLP in one case and hypertrophic LP in and Mahajan S et al. 14,15
the other). Vitiligo with 7 (12.5%) cases was the third most
frequently observed non-infective dermatosis in our study.
5. Conclusion
In the study by Mahajan S et al, 15 the most common non-
infectious entity was neuropathy with 8 (12.5%) cases.
In the present study results indicates pruritus was the most
We observed 5 (8.9%) cases of xanthelasmas, 4 (7.1%)
common symptom. 27.5% of patients sought dermatological
cases of acanthosis nigricans, 3 (5.4%) cases each of
advice primarily for cosmetic concern of their skin lesions,
diabetic neuropathy and perforating dermatoses, and 2
Infective dermatoses were more common than the non-
(3.6%) cases of bullosis diabeticorum.
infective dermatoses. Dermatophyte infections were slightly
In patients with acrochordons, lichen planus, acanthosis more common than muco-cutaneous candidal infections in
nigricans, perforating disorders, and granuloma annulare, our study. Tinea corporis/cruris was most common clinical
skin biopsies were performed, and the histopathological entity. 21.6% patients suffered from cutaneous bacterial
findings were consistent with the clinical diagnoses. infections in our study, the most frequently encountered
We came across 2 (1.7%) cases of diabetic dermopathy clinical entity being furunculosis. Staphylococcus aureus
and one case (0.8%) of diabetic rubeosis (rubeosis facie). The commonest non-infective clinical entity was acrochor-
Both these entities are hypothesized to be manifestations dons(skin tags). None of our patient presented with any
of diabetic microangiopathy. Rao GS et al, 16 observed only known cutaneous adverse reaction to any of the anti-diabetic
one (1.14%) patient with diabetic dermopathy. The apparent medication (OHA/lnsulin). Therefore, this results indictes
low prevalence of these two conditions among Indian high prevalence of skin disorders in DM patients. Careful
diabetics may be attributable to their dark complexion, dermatological examination and follow-up of diabetes
making it difficult to recognize the subtle color changes mellitus patients is required to provide them adequate skin
associated with them. management, thus reducing morbidity and complications
In our study, there were 8(6.7%) patients who presented related to skin. Further studies with large sample size are
with generalized pruritus, however no skin lesions could required.
144 Bose and Kumar / IP Indian Journal of Clinical and Experimental Dermatology 2020;6(2):136–144