Journal of the Euronean Academv of Dermatolow and Venereologv JEADV

-. ELSEVIER 4 (199;) 41-43 --

Skin diseases in children with type 1 diabetes mellitus

A. Verrotti a, F. Chiarelli a, P.L. Amerio by * , G. Morgese a a Department of Pediatrics, Universiry of Chieti, Italy

’ Department of Dermatology, Ospedale Pediatrico, Via Nicolini 1 I, 66100 Chieti, Italy

Abstract

Aim To evaluate the presence of skin diseases in diabetic children and adolescents and analyse the risk factors involved.

Background There are few studies in pediatric population with type 1 diabetes mellitus and these present conflicting results

Setting and Patients The Department of Pediatrics and Dermatology, University of Chieti, Italy. A group of 146 (86 female, 60 male) children. Their mean age + SD was 13.9 * 7.8 (range: 2.1-18.0) years; their duration of disease was 10.7 k 8.8 (range: 1.5-17.3) years.

Results Thirty-six patients showed skin problems: the most frequent disease was skin infection, followed by necrobiosis lipoidica; this last disorder is linked to the presence of microvascular complica- tions.

Conclusions The skin problems were more frequent in children with long duration of disease than in patients with a duration less than 7 years. All the patients who had limited joint mobility showed sclerodema. Dermatological evaluation is strongly reccomended in children with type 1 diabetes mellitus.

Keywords: Type 1 diabetes mellitus; Skin diseases in children

1. Introduction

Very often, patients suffering from type 1 (in- sulin-dependent) diabetes mellitus (IDDM) show various forms of cutaneous involvement during the course of their illness. It has been estimated that up to 30% of adult patients with diabetes

* Corresponding author. Tel/Fax: 0871/41272.

develop a skin lesion related to this disease [1,2]. The association of specific abnormalities such as necrobiosis lipoidica diabeticorum and diabetic dermopathy with IDDM is well recognized [3,4]. Many other skin diseases have been reported in diabetic patients, but there are very few studies on the pediatric population [5].

For this reason, we carried out a study to investigate what skin diseases are found in chil- dren with IDDM.

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42 A. Verrotti et al. /.I. Eur. Acad. Dennatol. Venereal. 4 (1995) 41-43

2. Patients and methods

We studied a group of 146 (86 female, 60 male) children with IDDM, followed at the Dia- betic Center of Chieti. Their mean age rt SD was 13.9 t- 7.8 (range: 2.1-18.0) years; their duration of disease was 10.7 f 8.8 (range: 1.5-17.3) years. Their subjects’ mean glycosylated haemoglobin (HbAlc) was 9.4 k 6.8 (6.9-15.4)%, and mean fructosamine was 261 k 182 (177-454) mcm/l. No patients received any drug except human in- sulin, from the day of the diagnosis.

The patients studied showed the following mi- crovascular complications: 30 persistent microal- buminuria (defined as albumin excretion rate > 20 pg/min in at least 3 overnight collections), 24 background or proliferative retinopathy (evalu- ated by fluorescein angiography), 36 electrophysi- ological signs of periferal neuropathy (assessed by nerve conduction velocity), 5 limited joint mobil- ity (assessed by prayer maneuver).

The diabetic patients were specifically exam- ined by a dermatologist. Glycosilated haemo- globin was measured by HPLC (BioRad Labora- tories, USA); fructosamine was measured by col- orimetry (Pharmacia, Sweden). Albumin excre- tion rate was assessed by RIA (Pharmacia, Swe- den). Statistical analysis was carried out by Stu- dent’s t test, the chi-square test and by regression analysis.

3. Results

Thirty-six patients (24.7% of all patients) showed skin disease. The various skin disease found in our patients are reported in Table 1. Some patients presented more than one skin problem. In three cases we performed a skin biopsy in order to confirm the diagnosis of sclere- dema. Moreover, for the diagnosis of scleredema, we used the criteria of Sattar [9]; our children showed classical scleredema with clinical charac- teristics similar to those seen in adults, but with- out any sort of dysprotidemia.

The patients were divided into three groups according to their HbAlc values: Group 1: HbAlc < 8.0%, Group 2: HbAlc 8.1-lO.O%,

Table 1 Skin problems in 146 pediatric IDDM patients

No. patients % M/F mean age: 15.1 k6.3 (range: 4.7-18.0) years

Infections 29 viral 7 bacterial 12 fungus 10

Acanthosis nigricans 2

Necrobiosis lipoidica 15

Lichen Ruber Planus 2

Vitiligo 9

Disseminated 2 Granuloma Annulare

80.5 19/10

5.5 l/l

41.6 5/10

5.5 l/l

25.0 5/4

5.5 l/l

Prurigo sine materia

Insulin-induced lipatrophy

7 19.4 3/4

6 16.6 4/2

Scleredema 5 13.8 2/3

Group 3: HbAlc > 10.0%. There was no signifi- cant difference of prevalence of skin disease among the three groups of patients. Moreover, we subdivided the patients into two groups ac- cording to duration of disease: Group A: < 7.0 years, Group B: > 7.0 years. There was a higher prevalence of skin disease in subjects with the longer duration of IDDM (chi-square = p < 0.001). The patients were divided also in prebu- pertal and pubertal children, but no significant difference of prevalence was found between these two groups.

We examined the mean HbAlc of children with skin infections, but they did not show a significant difference of HbAlc in comparison to the other patients. Moreover, the patients with poor-metabolic control did not show a higher prevalence of skin infections than children with good metabolic control.

The relationship between microvascular com- plications and skin disease, assessed by chi square test, showed the following results: only necrobio- sis lipoidica is associated significantly (p < 0.05) with the presence of retinopathy and nephropa- thy; all the other skin manifestations seemed in-

A. Verrotti et al. /J. Eur. Acad. Dermatol. Venereol. 4 (1995) 41-43 43

dependent of the microvascular complications. Finally, all the patients (4 female and 1 male children) who had limited joint mobility showed scleredema.

4. Discussion

Our study suggests that skin disease are not rare in children with type 1 diabetes mellitus and almost all types of dermatological problems re- ported in adult patients are presented also in pediatric age. Skin infections are one of the most frequent problems in our patients; in particular pyodermic infections, such as impetigo, folliculi- tis, foruncolosis, are more severe than in non-di- abetic patients. Generally it has been suggested that the incidence of cutaneous infections shows a correlation to the mean blood glucose levels [2,6], but we failed to demonstrate this associa- tion.

Moreover, necrobiosis lipoidica is frequent and it seems to be related to the presence of mi- crovascular complications. In agreement with other authors [7], female patients were affected 2 times more often than male patients. As sug- gested by Boulton et al. [B], there is no treatment to reverse the atrophic changes.

Finally, scleroedema diabeticorum was ob- served in our population and all patients showed limited joint mobility; this association suggests that impaired glycosilation and degradation with consequent increased production of glycosamino- glycans and collagen abnormality may be at the base of this complication 19,101.

As in other series [1,2,5,11] it is difficult to identify the main risk factors of skin disease; in our experience, the quality of metabolic control

seems not to be an important risk factor, nor is the age of the patients. On the other hand, the duration of diabetes mellitus is significantly re- lated to the prevalence of skin diseases.

In conclusion, our study suggests that dermato- logical complications are not rare in pediatric patients with IDDM, in particular after some years of disease, and they may be associated with microvascular complications.

References

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