ISPAD 2018 guidelines: Diagnosis & treatment of insulin-induced, and other common skin conditions in T1D
M3 India Newsdesk Jun 13, 2019
Type 1 Diabetes (T1D) in children and adolescents brings along quite a few skin conditions. This guideline lists the common dermatological conditions linked to T1D- specifically, Lipohypertrophy, Lipoatrophy, NLD, Vitiligo, and Psoriasis and their diagnosis, treatment and management as mentioned in the International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guidelines 2018 Compendium.
Important recommendations include:
- Educating patients about using correct injection techniques, rotating injection sites and using only fresh needles as ways to prevent lipohypertrophy and lipoatrophy.
- Assessing injection sites regularly during each clinic visit to check for lipohypertrophy and lipoatrophy as they are potential causes of glucose variability.
Lipohypertrophy is one of the most common dermatological complications of subcutaneous insulin administration. It is characterised by fibrous and poorly vascularised lesions in the subcutaneous adipose tissue. The cause of its occurrence is the direct anabolic effect of insulin on local skin, leading to fat and protein synthesis, and because of repeated injections at the same site.
Areas with lipohypertrophy are relatively painless and so, patients tend to use the same area for injections. Other possible risk factors related to lipohypertrophy are longer duration of insulin therapy, high number of insulin injections and use of already used needles instead of fresh ones. The presence of lipohypertrophy can be easily missed as the initial skin changes are quite subtle and show up only as thickening of the skin.
- Detecting lipohypertrophy can be difficult as visual inspection does not always help with accurate diagnosis. However, palpation of the sites of injection can help identify the soft, lipoma-like nodules
- The patient should be asked to visit the clinic regularly for examination and the healthcare professional should carefully examine the injection sites for possible lipohypertrophy
- Individuals should also be educated on examining their skin on the injection sites and detecting lipohypertrophy
- Assume the patient can do so correctly, then he or she should be advised to not use the same site to inject until the abnormal tissue starts to appear normal; this can take several months
The best measures to prevent lipohypertrophy include, educating patients regarding proper injection techniques, rotating injection sites each time and using fresh needles every time instead of reusing them.
Lipoatrophy is a form of localised lipodystrophy and a known complication of insulin therapy. It is often characterised by a disfiguring loss of subcutaneous fat at the site, where insulin injections are taken. Also, it could be the result of a lipolytic reaction to impurities or other components in some insulin preparations.
The body’s mechanism of lipoatrophy is not well-understood but perhaps, it is the immune pathogenesis that is at work. This could also be the reason why it is common in T1D patients, besides other symptoms of autoimmunity.
As per theories, other factors include cryotrauma from refrigerated insulin, mechanical trauma due to the angle of injection, surface alcohol contamination, or local hyperproduction of tumour necrosis factor alpha from macrophages induced by injected insulin.
It should be noted and explained to the patient that repeated use of the same insulin injection site for CSII or even injections and using the same needle multiple times increases the risk of lipoatrophy.
The patient should be strictly advised to visit the clinic regularly for examination. The healthcare professional should carefully examine the injection sites for possible lipoatrophy each time.
- Treatment may include changing the site of injection or CSII and switching insulin analogues. These options may or may not prove effective in completely resolving lesions.
- As per an observation made in the ISPAD compendium, treatment with steroids, given orally (daily low-dose prednisolone) or injection of dexamethasone into the lipoatrophic lesions led to the return of subcutaneous fat tissue in a few cases.
Necrobiosis Lipoidica Diabeticorum (NLD)
Necrobiosis lipoidica is a rare, chronic granulomatous dermatitis, which is characterised by plaques on the shins of tibia with the appearance of red-brown edges and atrophic, yellow-brown, telangiectatic centers.
Although these are commonly asymptomatic, the affected skin can be fragile and painful ulcerations may show up. As per observations made in the ISPAD Compendium, it is the pretibial region, which is typically affected, and very rarely does it appear on the hands, fingers, face, and the scalp of patients.
Necrobiosis lipoidica could be one of the possible manifestations of microangiopathy. However, whether the impact of poor glucose control is a causative factor in the development and progression of necrobiosis lipoidica lesion, remains controversial as there is limited data available in the pediatric cases studied.
The treatment of necrobiosis lipoidica is challenging; the initial therapy is topical, intralesional or systemic corticosteroids, but the responses to these treatments are not always consistent.
Vitiligo vulgaris or skin depigmentation is a common skin condition among T1D children and adolescent patients.
For detecting vitiligo vulgaris, measuring 25-hydroxyvitamin D levels and supplementation should be considered. This is suggested as per an observation made in the ISPAD Compendium, which states that vitamin D deficiency is common in people with vitiligo.
- Treatment of vitiligo does not garner satisfactory results. However, patients should be advised to avoid the sun and use broad-spectrum sunscreens.
- For localised vitiligo, topical corticosteroids or calcineurin inhibitor-based creams are recommended. And for generalised vitiligo, treatment with ultraviolet-B light treatment can be tried.
Psoriasis is a common skin condition in T1D patients. As per an observation made in the ISPAD Compendium, the condition is consistent with a common autoimmune predisposition.
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