Reviews

Skin manifestations of diabetes

Cleveland Clinic Journal of Medicine. 2008 November;75(11):772, 774, 776-777, 780-787

ABSTRACTDiabetes mellitus can be complicated by a variety of cutaneous manifestations. Good metabolic control may prevent some of these manifestations and may support cure. Unfortunately, most glucose-lowering drugs also have cutaneous side effects. It is important to be able to recognize these signs and symptoms and to either treat them appropriately or refer the patient to a dermatologist or diabetologist.

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KEY POINTS

Patients with type 2 diabetes more often develop skin infections, whereas those with type 1 more often have autoimmune-related lesions.
Insulin signaling supports normal skin proliferation, differentiation, and maintenance, and a lack of insulin may lead to impaired wound healing, which may affect insulin resorption.
Skin manifestations of diabetes may also serve as ports of entry for secondary infection.
A candidal infection (moniliasis) can be an early sign of undiagnosed diabetes.
Watch for dermal side effects of insulin injections and oral hypoglycemic drugs.

References

Landau J, Davis E. The small blood-vessels of the conjunctiva and nail bed in diabetes mellitus. Lancet 1960; 2:731
Huntley A. Diabetes mellitus: review. Dermatology Online Journal 1995; vol 1(2). http://dermatology.cdlib.org/DOJvol1num2/diabetes/dmreview.html. Accessed July 30, 2008.
Ahmed I, Goldstein B. Diabetes mellitus. Clin Dermatol 2006; 24:237–246.
Petzelbauer P, Wolff K, Tappeiner G. Necrobiosis lipoidica: treatment with systemic corticoids. Br J Dermatol 1992; 126:542.
Sibbald RG, Schachter RK. The skin and diabetes mellitus. Int J Dermatol 1984; 23:567–584.
Ferringer T, Miller F. Cutaneous manifestations of diabetes mellitus. Dermatol Clin 2002; 20:483–492.
Cohen O, Yaniv R, Karasik A, Trau H. Necrobiosis lipoidica and diabetic control revisited. Med Hypotheses 1996; 46:348–350.
Nguyen K, Washenik K, Shupak J. Necrobiosis lipoidica diabeticorum treated with chloroquine. J Am Acad Dermatol 2002; 46 suppl 2:34–36.
Stanway A, Rademaker M, Newman P. Healing of severe ulcerative necrobiosis lipoidica with cyclosporine. Australas J Dermatol 2004; 45:119–122.
Dittmar M, Kahaly GJ. Polyglandular autoimmune syndromes: immunogenetics and long-term follow-up. J Clin Endocrinol Metab 2003; 88:2983–2992.
Forschner T, Buchholtz S, Stockfleth E. Current state of vitiligo therapy-evidence-based analysis of the literature. J Dtsch Dermatol Ges 2007; 5:467–475.
Petrou-Amerikanou C, Markopoulos AK, Belazi M, Karamitsos D, Papanayotou P. Prevalence of oral lichen planus in diabetes mellitus according to the type of diabetes. Oral Dis 1998; 4:37–40.
Mobini N, Toussaint S, Kamino H. Noninfectious, erythematous, papular, and squamous diseases. In:Elder DE, editor. Lever’s Histopathology of the Skin. 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2005:179–214.
Nikoleishvili LR, Kurashvili RB, Virsaladze DK. Characteristic changes of skin and its accessories in type 2 diabetes mellitus. Georgian Med News 2006; 131:43–46.
Lithner F, Hietala S-O. Skeletal lesions of the feet in diabetics and their relationship to cutaneous erythema with or without necrosis of the feet. Acta Med Scand 1976; 200:155–161.
Collier A, Matthews DM, Kellett HA, Clarke BF, Hunter JA. Change in skin thickness associated with cheiroarthropathy in insulin dependent diabetes mellitus. Br Med J (Clin Res Ed) 1986; 292:936.
Perez MI, Kohn SR. Cutaneous manifestations of diabetes mellitus. J Am Acad Dermatol 1994; 30:519–530.
Libecco JF. Finger pebbles and diabetes: a case with broad involvement of the dorsal fingers and hands. Arch Dermatol 2001; 137:510–511.
Brik R, Berant M, Vardi P. The scleroderma-like syndrome of insulin-dependent diabetes mellitus. Diabetes Metab Rev 1991; 7:121–128.
Jelinek JE. Cutaneous manifestations of diabetes mellitus. Int J Dermatol 1994; 33:605–617.
Huntley AC. The cutaneous manifestations of diabetes mellitus. J Am Acad Dermatol 1989; 7:427–455.
Jennings AM, Milner PC, Ward JD. Hand abnormalities are associated with the complications of diabetes in type 2 diabetes. Diabet Med 1989; 6:43–47.
Cole GW, Headley J, Skowsky R. Scleredema diabeticorum: a common and distinct cutaneous manifestation of diabetes mellitus. Diabetes Care 1983; 6:189–192.
Kahana M, Grossman E, Feinstein A, Ronnen M, Cohen M, Millet MS. Skin tags: a cutaneous marker for diabetes mellitus. Acta Derm Venereol 1987; 67:175–177.
Margolis J, Margolis LS. Skin tags—a frequent sign of diabetes mellitus [letter]. N Engl J Med 1976; 294:1184.
Garcia Hidalgo L. Dermatological complications of obesity. Am J Clin Dermatol 2002; 3:497–506.
Scheinfeld NS. Obesity and dermatology. Clin Dermatol 2004; 22:303–309.
Crook MA. Skin tags and the atherogenic lipid profile. J Clin Pathol 2000; 53:873–874.
Tompkins RR. Skin tags and diabetes. Arch Dermatol 1977; 113:1463.
Sibbald RG, Landolt SJ, Toth D. Skin and diabetes. Endocrinol Metab Clin North Am 1996; 25:463–472.
Hermanns-Le T, Scheen A, Pierard GE. Acanthosis nigricans associated with insulin resistance: pathophysiology and management. Am J Clin Dermatol 2004; 5:199–203.
Katz RA. Treatment of acanthosis nigricans with oral isotretinoin. Arch Dermatol 1980; 116:110.
Morton CA, Henderson IS, Jones MC, Lowe JG. Acquired perforating dermatosis in a British dialysis population. Br J Dermatol 1996; 135:671–677.
Saray Y, Seçkin D, Bilezikçi B. Acquired perforating dermatosis: clinicopathological features in twenty-two cases. J Eur Acad Dermatol Venereol 2006; 20:679–688.
Wilmer WA, Magro CM. Calciphylaxis:emerging concepts in prevention, diagnosis, and treatment. Dialysis 2002; 15:172–186.
Muller SA. Dermatologic disorders associated with diabetes mellitus. Mayo Clin Proc 1966; 41:689.
Meurer M, Stumvoll M, Szeimies RM. Hautveränderungen bei Diabetes mellitus. Hautartz 2004; 55:428–435.
Grammer L. Insulin allergy. Clin Rev Allergy 1986; 4:189–200.
Richardson T, Kerr D. Skin-related complications of insulin therapy: epidemiology and emerging management strategies. Am J Clin Dermatol 2003; 4:661–667.
Murao S, Hirata K, Ishida T, Takahara J. Lipoatrophy induced by recombinant human insulin injection. Intern Med 1998; 37:1031–1033.
Barranco R, Herrero T, Tornero P, et al. Systemic allergic reaction by a human insulin analog. Allergy 2003; 58:536–537.
Burge MR, Carey JD. Vitiligo associated with subcutaneous insulin lispro infusion in type 1 diabetes. Diabetes Care 2004; 27:275–276.
Durand-Gonzalez KN, Guillausseau N, Pecquet C, Gayno JP. Glargine insulin is not an alternative in insulin allergy. Diabetes Care 2003; 26:2216.
Blumer IR. Severe injection site reaction to insulin detemir. Diabetes Care 2006; 29:946.
Darmon P, Castera V, Koeppel MC, Petitjean C, Dutour A. Type III allergy to insulin detemir. Diabetes Care 2005; 28:2980.
Deerochanawong C, Chandraprasert S. Glimepiride in type 2 diabetes mellitus Thai patients. J Med Assoc Thai 2001; 84:1221–1228.
Noakes R. Lichenoid drug eruption as a result of the recently released sulfonylurea glimepiride. Australas J Dermatol 2003; 44:302–303.
Koca R, Altinyazar HC, Yenidünya S, Tekin NS. Psoriasiform [sic] drug eruption associated with metformin hydrochloride: a case report. Dermatol Online J 2003; 9:11. http://dermatology.cdlib.org/93/case_reports/metformin/koca.html. Accessed July 30, 2008.
Burger DE, Goyal S. Erythema multiforme from metformin. Ann Pharmacother 2004; 38:1537.
Klapholz L, Leitersdorf E, Weinrauch L. Leucocytoclastic vasculitis and pneumonitis induced by metformin. BMJ (Clin Res Ed) 1986; 293:483.
Ben Salem C, Hmouda H, Slim R, Denguezli M, Belajouza C, Bouraoui K. Rare case of metformin-induced leucocytoclastic vasculitis. Ann Pharmacother 2006; 40:1685–1687.
Litt JZ. Litt’s Drug Eruption Reference Manual. London: Taylor and Francis, 2001.
Balfour JA, McTavish D. Acarbose: an update of its pharmacology and therapeutic use in diabetes mellitus. Drugs 1993; 46:1024–1054. Erratum in: Drugs 1994; 48:929.
Kono T, Hayami M, Kobayashi H, Ishii M, Taniguchi S. Acarbose-induced generalized erythema multiforme. Lancet 1999; 354:396–397.
Ahr HJ, Boberg M, Krause HP, et al. Pharmacokinetics of acarbose. Part 1: Absorption, concentration in plasma, metabolism, and excretion after single administration of 14C acarbose to rats, dogs and man. Arzneimittelforschung 1989; 39:1254–1260.
Poszepczynska-Guigné E, Viguier M, Assier H, Pinquier L, Hochedez P, Dubertret L. Acute generalized exanthematous pustulosis induced by drugs with low-digestive absorption: acarbose and nystatin. Ann Dermatol Venereol 2003; 130:439–442.

Almost all diabetic patients eventually develop skin complications from the long-term effects of diabetes mellitus on the microcirculation and on skin collagen. Cutaneous infections are more common in type 2 diabetes, whereas autoimmune-related lesions are more common in type 1. Patients who have had diabetes for many years tend to develop the most devastating skin problems. However, problems can also develop in the short term, as insulins and oral hypoglycemic drugs can also have dermal side effects. Furthermore, diabetes-related cutaneous lesions may also serve as a port of entry for secondary infection.

This review aims to guide the clinician to the correct diagnosis of cutaneous manifestations associated with type 1 (Table 1) and type 2 (Table 2) diabetes mellitus, to recognize cutaneous side effects of glucose-lowering drugs, and to aid the treatment of diabetic skin disease. The classification and treatment of the diabetic foot are not within the scope of this review.

MANIFESTATIONS ASSOCIATED WITH TYPE 1 DIABETES

Periungual telangiectasia

The lesions of periungual telangiectasia, appearing as red, dilated, capillary veins, are easily visible with the naked eye and are the result of a loss of capillary loops and dilation of the remaining capillaries. A prevalence up to 49% has been described in all diabetic patients.¹ Connective tissue diseases may also involve periungual telangiectases, although these lesions are morphologically different. In diabetes, periungual telangiectasia is often associated with nail fold erythema, accompanied by fingertip tenderness and “ragged” cuticles.²

Necrobiosis lipoidica

Figure 1. General appearance of necrobiosis lipoidica, consisting of nonscaling plaques in the pretibial region of the legs.

Necrobiosis lipoidica diabeticorum (Figure 1) appears in 0.3% to 1.6% of diabetic patients. Its origin is unknown. The fully developed clinical appearance is diagnostic: nonscaling plaques with a yellow atrophic center, surface telangiectases, and an erythematous or violaceous border that may be raised. The pretibial region is the area typically affected. Ulceration occurs in up to 35% of cases. Women are affected more often than men. Patients with type 1 diabetes develop necrobiosis lipoidica at an earlier mean age than those with type 2 and those without diabetes. The yellow aspect in the central area of the lesions is most likely due to thinning of the dermis, making subcutaneous fat more visible.^3–5

Metabolic control has no proven effect on the course of this condition,⁶ although Cohen et al⁷ reported that tight glucose control reduced the incidence in diabetic patients. Treatment includes application of a topical steroid with or without occlusion; intralesional steroids at the active border; or, in the rare severe or extensive case, systemic steroids.^6,7 In some resistant cases, aspirin, chloroquine (Aralen), and cyclosporine (Sandimmune, Neoral) have been used with some success.^3,8,9

Bullosis diabeticorum

Bullosis diabeticorum develops in approximately 0.5% of diabetic patients, but more often in those with type 1 diabetes, and more often in men and in patients with long-standing diabetes with peripheral neuropathy. It presents as asymptomatic bullae containing sterile fluid on a noninflamed base, usually arising spontaneously on the dorsa and sides of the lower legs and feet, sometimes on the hands or the forearms. The cause is unknown, and it is a diagnosis of exclusion. The differential diagnosis includes epidermolysis bullosa acquisita, porphyria cutanea tarda, bullous pemphigoid, bullous impetigo, coma blisters, and erythema multiforme.

Treatment is symptomatic and conservative. In case of discomfort, the bullae can be aspirated (leaving the blister roof intact), or compresses can be used. Topical antibiotics may be required to prevent secondary infection.³ Most lesions resolve in 2 to 3 weeks without residual scarring.^5,6

Vitiligo

Vitiligo vulgaris, or skin depigmentation, occurs more often in type 1 diabetic patients. From 1% to 7% of all diabetic patients have vitiligo vs 0.2% to 1% of the general population. The mechanism behind the association has not been elucidated, although some have suggested polyglandular autoimmune syndrome (PAS), a rare immune endocrinopathy characterized by the coexistence of at least two endocrine gland insufficiencies that are based on autoimmune mechanisms. PAS type 2 is more common (estimated prevalence of 1:20,000), occurs mainly in the third or fourth decade, and is characterized by adrenal failure, autoimmune thyroid disease, or type 1 diabetes. Adrenal failure may precede other endocrinopathies. Vitiligo and gonadal failure occur more frequently in PAS type 1 than in PAS type 2, whereas immunogastritis, pernicious anemia, and alopecia areata are the main features of PAS type 2. In contrast to PAS type 1, family members of PAS type 2 patients are often affected as well. PAS type 2 is believed to be polygenic, with an autosomal dominant pattern of inheritance.¹⁰

Treatment of vitiligo is unsatisfactory in general. Patients should be advised to avoid the sun and to use broad-spectrum sunscreens. For localized vitiligo, topical corticosteroids are preferred, whereas for generalized vitiligo ultraviolet B light treatment is most effective. Cosmetic treatment is an option for improved well-being.¹¹

Oral lichen planus

Figure 2. Lichen ruber planus typically presents on the skin as flat, polygonal, erythematous lesions of the lower legs, and also on the wrists and the dorsal areas of the feet.

The association between diabetes and lichen planus (Figure 2), especially oral lichen planus, has been the subject of much research. However, most studies have examined the prevalence of diabetes mellitus in patients with lichen planus, rather than the reverse. Also, many reports do not differentiate between the types of diabetes. Petrou-Amerikanou et al¹² reported a significantly higher prevalence of oral lichen planus in type 1 diabetic patients vs a control population, but not in type 2 diabetic patients.

Clinically, lichen planus presents as polygonal erythematous flat lesions. Most often affected are the wrists, the dorsa of the feet, and the lower legs. Oral lichen planus presents as white stripes in a reticular pattern.

Clinical and histopathologic differentiation of these lesions from lichenoid reactions to drugs (eg, nonsteroidal anti-inflammatory drugs, antihypertensive drugs) may be difficult, although numerous eosinophils, parakeratosis, and perivascular inflammation around the mid and deep dermal plexuses, are seen in lichenoid drug reactions, but generally not in lichen planus.¹³

Treatment consists of topical corticosteroids or topical cyclosporine, or both.⁶

References

Landau J, Davis E. The small blood-vessels of the conjunctiva and nail bed in diabetes mellitus. Lancet 1960; 2:731
Huntley A. Diabetes mellitus: review. Dermatology Online Journal 1995; vol 1(2). http://dermatology.cdlib.org/DOJvol1num2/diabetes/dmreview.html. Accessed July 30, 2008.
Ahmed I, Goldstein B. Diabetes mellitus. Clin Dermatol 2006; 24:237–246.
Petzelbauer P, Wolff K, Tappeiner G. Necrobiosis lipoidica: treatment with systemic corticoids. Br J Dermatol 1992; 126:542.
Sibbald RG, Schachter RK. The skin and diabetes mellitus. Int J Dermatol 1984; 23:567–584.
Ferringer T, Miller F. Cutaneous manifestations of diabetes mellitus. Dermatol Clin 2002; 20:483–492.
Cohen O, Yaniv R, Karasik A, Trau H. Necrobiosis lipoidica and diabetic control revisited. Med Hypotheses 1996; 46:348–350.
Nguyen K, Washenik K, Shupak J. Necrobiosis lipoidica diabeticorum treated with chloroquine. J Am Acad Dermatol 2002; 46 suppl 2:34–36.
Stanway A, Rademaker M, Newman P. Healing of severe ulcerative necrobiosis lipoidica with cyclosporine. Australas J Dermatol 2004; 45:119–122.
Dittmar M, Kahaly GJ. Polyglandular autoimmune syndromes: immunogenetics and long-term follow-up. J Clin Endocrinol Metab 2003; 88:2983–2992.
Forschner T, Buchholtz S, Stockfleth E. Current state of vitiligo therapy-evidence-based analysis of the literature. J Dtsch Dermatol Ges 2007; 5:467–475.
Petrou-Amerikanou C, Markopoulos AK, Belazi M, Karamitsos D, Papanayotou P. Prevalence of oral lichen planus in diabetes mellitus according to the type of diabetes. Oral Dis 1998; 4:37–40.
Mobini N, Toussaint S, Kamino H. Noninfectious, erythematous, papular, and squamous diseases. In:Elder DE, editor. Lever’s Histopathology of the Skin. 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2005:179–214.
Nikoleishvili LR, Kurashvili RB, Virsaladze DK. Characteristic changes of skin and its accessories in type 2 diabetes mellitus. Georgian Med News 2006; 131:43–46.
Lithner F, Hietala S-O. Skeletal lesions of the feet in diabetics and their relationship to cutaneous erythema with or without necrosis of the feet. Acta Med Scand 1976; 200:155–161.
Collier A, Matthews DM, Kellett HA, Clarke BF, Hunter JA. Change in skin thickness associated with cheiroarthropathy in insulin dependent diabetes mellitus. Br Med J (Clin Res Ed) 1986; 292:936.
Perez MI, Kohn SR. Cutaneous manifestations of diabetes mellitus. J Am Acad Dermatol 1994; 30:519–530.
Libecco JF. Finger pebbles and diabetes: a case with broad involvement of the dorsal fingers and hands. Arch Dermatol 2001; 137:510–511.
Brik R, Berant M, Vardi P. The scleroderma-like syndrome of insulin-dependent diabetes mellitus. Diabetes Metab Rev 1991; 7:121–128.
Jelinek JE. Cutaneous manifestations of diabetes mellitus. Int J Dermatol 1994; 33:605–617.
Huntley AC. The cutaneous manifestations of diabetes mellitus. J Am Acad Dermatol 1989; 7:427–455.
Jennings AM, Milner PC, Ward JD. Hand abnormalities are associated with the complications of diabetes in type 2 diabetes. Diabet Med 1989; 6:43–47.
Cole GW, Headley J, Skowsky R. Scleredema diabeticorum: a common and distinct cutaneous manifestation of diabetes mellitus. Diabetes Care 1983; 6:189–192.
Kahana M, Grossman E, Feinstein A, Ronnen M, Cohen M, Millet MS. Skin tags: a cutaneous marker for diabetes mellitus. Acta Derm Venereol 1987; 67:175–177.
Margolis J, Margolis LS. Skin tags—a frequent sign of diabetes mellitus [letter]. N Engl J Med 1976; 294:1184.
Garcia Hidalgo L. Dermatological complications of obesity. Am J Clin Dermatol 2002; 3:497–506.
Scheinfeld NS. Obesity and dermatology. Clin Dermatol 2004; 22:303–309.
Crook MA. Skin tags and the atherogenic lipid profile. J Clin Pathol 2000; 53:873–874.
Tompkins RR. Skin tags and diabetes. Arch Dermatol 1977; 113:1463.
Sibbald RG, Landolt SJ, Toth D. Skin and diabetes. Endocrinol Metab Clin North Am 1996; 25:463–472.
Hermanns-Le T, Scheen A, Pierard GE. Acanthosis nigricans associated with insulin resistance: pathophysiology and management. Am J Clin Dermatol 2004; 5:199–203.
Katz RA. Treatment of acanthosis nigricans with oral isotretinoin. Arch Dermatol 1980; 116:110.
Morton CA, Henderson IS, Jones MC, Lowe JG. Acquired perforating dermatosis in a British dialysis population. Br J Dermatol 1996; 135:671–677.
Saray Y, Seçkin D, Bilezikçi B. Acquired perforating dermatosis: clinicopathological features in twenty-two cases. J Eur Acad Dermatol Venereol 2006; 20:679–688.
Wilmer WA, Magro CM. Calciphylaxis:emerging concepts in prevention, diagnosis, and treatment. Dialysis 2002; 15:172–186.
Muller SA. Dermatologic disorders associated with diabetes mellitus. Mayo Clin Proc 1966; 41:689.
Meurer M, Stumvoll M, Szeimies RM. Hautveränderungen bei Diabetes mellitus. Hautartz 2004; 55:428–435.
Grammer L. Insulin allergy. Clin Rev Allergy 1986; 4:189–200.
Richardson T, Kerr D. Skin-related complications of insulin therapy: epidemiology and emerging management strategies. Am J Clin Dermatol 2003; 4:661–667.
Murao S, Hirata K, Ishida T, Takahara J. Lipoatrophy induced by recombinant human insulin injection. Intern Med 1998; 37:1031–1033.
Barranco R, Herrero T, Tornero P, et al. Systemic allergic reaction by a human insulin analog. Allergy 2003; 58:536–537.
Burge MR, Carey JD. Vitiligo associated with subcutaneous insulin lispro infusion in type 1 diabetes. Diabetes Care 2004; 27:275–276.
Durand-Gonzalez KN, Guillausseau N, Pecquet C, Gayno JP. Glargine insulin is not an alternative in insulin allergy. Diabetes Care 2003; 26:2216.
Blumer IR. Severe injection site reaction to insulin detemir. Diabetes Care 2006; 29:946.
Darmon P, Castera V, Koeppel MC, Petitjean C, Dutour A. Type III allergy to insulin detemir. Diabetes Care 2005; 28:2980.
Deerochanawong C, Chandraprasert S. Glimepiride in type 2 diabetes mellitus Thai patients. J Med Assoc Thai 2001; 84:1221–1228.
Noakes R. Lichenoid drug eruption as a result of the recently released sulfonylurea glimepiride. Australas J Dermatol 2003; 44:302–303.
Koca R, Altinyazar HC, Yenidünya S, Tekin NS. Psoriasiform [sic] drug eruption associated with metformin hydrochloride: a case report. Dermatol Online J 2003; 9:11. http://dermatology.cdlib.org/93/case_reports/metformin/koca.html. Accessed July 30, 2008.
Burger DE, Goyal S. Erythema multiforme from metformin. Ann Pharmacother 2004; 38:1537.
Klapholz L, Leitersdorf E, Weinrauch L. Leucocytoclastic vasculitis and pneumonitis induced by metformin. BMJ (Clin Res Ed) 1986; 293:483.
Ben Salem C, Hmouda H, Slim R, Denguezli M, Belajouza C, Bouraoui K. Rare case of metformin-induced leucocytoclastic vasculitis. Ann Pharmacother 2006; 40:1685–1687.
Litt JZ. Litt’s Drug Eruption Reference Manual. London: Taylor and Francis, 2001.
Balfour JA, McTavish D. Acarbose: an update of its pharmacology and therapeutic use in diabetes mellitus. Drugs 1993; 46:1024–1054. Erratum in: Drugs 1994; 48:929.
Kono T, Hayami M, Kobayashi H, Ishii M, Taniguchi S. Acarbose-induced generalized erythema multiforme. Lancet 1999; 354:396–397.
Ahr HJ, Boberg M, Krause HP, et al. Pharmacokinetics of acarbose. Part 1: Absorption, concentration in plasma, metabolism, and excretion after single administration of 14C acarbose to rats, dogs and man. Arzneimittelforschung 1989; 39:1254–1260.
Poszepczynska-Guigné E, Viguier M, Assier H, Pinquier L, Hochedez P, Dubertret L. Acute generalized exanthematous pustulosis induced by drugs with low-digestive absorption: acarbose and nystatin. Ann Dermatol Venereol 2003; 130:439–442.

Skin manifestations of diabetes

References

Periungual telangiectasia

Necrobiosis lipoidica

Bullosis diabeticorum

Vitiligo

Oral lichen planus

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