Diabetes & Dermatology: Uncovering Skin Conditions in Diabetic Patients

Dr. Anderson:
Welcome to Diabetes Discourse on ReachMD. I'm Dr. John Anderson, and joining me today to help uncover skin conditions that might present in our diabetic patients is actually one of my fellow ReachMD hosts, Dr. Michael Greenberg. Michael, you care to introduce yourself to the audience?

Dr. Greenberg:
Thanks. I'm Dr. Michael Greenberg. I'm the host of DermConsult here on ReachMD. And I've been a dermatologist for over 43 years. It's a long time. I've seen a lot of skin.

Dr. Anderson:
Thanks, Michael. So, let's just dive into this discussion. The American Academy published an article about 12 warning signs that appear in skin on patients with diabetes for the general public. Can you walk us through this? Maybe in no particular order? What do you see most commonly?

Dr. Greenberg:
Well, the most common thing I see and, I gotta be honest with you, John, I've really, up until I read this article and talked about the show, I really haven't been aware of looking for diabetes. I've seen these other things. And the most common thing that I see is acanthosis nigricans. You see it all the time and patients, and I don't normally think of diabetes.

Dr. Anderson:
But tell us a little bit about that. What do you do? What does it look like? How do you treat it?

Dr. Greenberg:
Well, it looks like a black velvety covering. And it's usually around the neck. It's very often in people of color, very often in women who are more overweight. And basically what I do is give topical medications that have the salicylic acid or something to just peel off the extra skin. So it's almost treated by me on a daily basis, and by a lot of dermatologists as a cosmetic issue, not a warning sign that we should be looking for diabetes. So, I'm glad we brought this up.

Dr. Anderson:
Have you had occasion where you’ve seen this on a patient and said, ‘Hey, have you been to your primary care provider? Has anybody done a glucose?’ Has that ever happened with you?

Dr. Greenberg:
Well, I certainly will in the future after this show. Sometimes I've asked patients about their general health and they'll bring up the fact that they're diabetic. So, bring these two things together. I have to honestly say I've never sent a patient for a glucose test on the basis of that diagnosis. That's why this show is so important.

Dr. Anderson:
Talk to us about other common skin conditions you see in people with diabetes.

Dr. Greenberg:
Well, I do see necrobiosis once in a while. And that of course, you know, it's necrobiosis lipoidica diabeticorum. It's a long name, but when I see that in my office, I take a biopsy and make that diagnosis, that's for sure, ‘Hey, have you been to your internist? Have you had a blood sugar? Do you realize you might have diabetes?’ And I would say about half the time, patients know that they're diabetic. And they’re actually sent to me by their internist for a biopsy to confirm the diagnosis. It’s a little bit more difficult to treat. But that's definitely one of the warning signs of diabetes.

Dr. Anderson:
Other than seeing it on the skin, are patients symptomatic in any way from necrobiosis? 

Dr. Greenberg:
Well, they're symptomatic in the way they hate the way it looks. And sometimes it's a little bit painful, but usually not. Usually, it's just an area of the skin that looks like it's waxy and looks like it's dead. That's what the name means, necrobiosis, living death.

Dr. Anderson:
What other conditions do you see commonly that are in that top 12 that the Academy listed?

Dr. Greenberg:
Well, I've got to tell you, they listed a lot of things that were just pigmentary changes and I think it behooves every dermatologist to look this article up and read these things, because a lot of the changes are papules, red papules, just nonspecific things that wouldn't make me think of diabetes. But once again, I'm sure going to after this.

Skin tags, now there's an interesting one that they listed. I see skin tags every day. It’s purely a cosmetic problem on patients. And I don't tend to think about skin tags as being diabetes or as representing a diabetic skin change. But as I sit here today and talk to you, I keep thinking about the people who get skin tags very often are more obese, or at least overweight. And yeah, they probably are setups for diabetes, or have it and I’m going in reverse. This is an eye opener. I'm not talking about a healthy 18-year-old kid yesterday came with two skin tags on his neck. I'm talking about the large person who's sitting across from me, who has 5,000 skin tags and wants them removed.

Dr. Anderson:
It's my experience too in areas of irritation or rubbing, and it's my experience as well that the more overweight to obese patient population tends to have a lot more of these. That's true. Well, you've got 43 years of experience, as you said. Have you had cases where you go, ‘Wow, I had no idea that that occurred because of the patient's diabetes?'

Dr. Greenberg:
I had a patient who came into my office who was grossly obese, didn't take care of himself, and he presented with huge bullae on his legs. Huge. They were secondarily infected. And of course, as a dermatologist with my training, I went right for, ‘Hey, let's biopsy this because it's probably going to be pemphigus or pemphigoid, or one of those or bullous impetigo.’ And, whoa, to my surprise, there were no immunoglobulins in the skin. It wasn't even really infected. It was purely bullae from his diabetes. And it's the first time in 43 years I've ever seen that. And I was glad to make the diagnosis, because that's a lot better diagnosis to treat, and a lot easier. But talk about an apropos diagnosis leading into a show like this. I think it's something we need to look at.

Dr. Anderson:
Do most of your referrals with patients with diabetes who have unique skin conditions, do they come from their primary care provider, endocrinologist, internist? Is that usually the way it happens? Or do you get a lot of self-referral as well?

Dr. Greenberg:
I get a lot of self-referral in my practice, but most of that's coming from the diabetologist at the internist, saying, ‘Hey, is this necrobiosis? Please biopsy it for me. What's going on here? What is with this rash?’ And with all the pigmentary change type rashes I very often don't diagnose it; we try and treat it topically. And sometimes when you hear the hoofbeats down the street, don't look for the zebras; it's the horses. Most often it's really just eczema. It's really not a diabetic change, and it clears up pretty quickly with topical steroids.

Dr. Anderson:
For those just tuning in. You're listening to Diabetes Discourse on ReachMD. I'm Dr. John Anderson, and today I'm speaking with my fellow ReachMD host, Dr. Michael Greenberg, about skin conditions that are common in people with diabetes. Michael, have you had a pretty easy time working with primary care providers and endocrinologists? Is there a good way to communicate?

Dr. Greenberg:
I always believe in picking up the phone and calling somebody; I'm an old-fashioned dinosaur type of guy. I don't like to send text messages or emails. And I think it's very important to communicate with patient’s internals from time to time, not all the time, not on the average patient with acne or eczema. But when something is diabetic, when I'm getting a necrobiosis, I pick up the phone and call. Now, the practical problem in dealing with other doctors is trying to get a hold of them on the telephone. That is so difficult. And I would urge anybody listening to this show, all of our fellow doctors, make yourself available when another physician calls. I think it's really important, really key. And the best patient outcomes that I've had is when I can call a doctor's office, and they either call me back in a few minutes, or pick up the phone right away. And don't wait a week to call me or forget to call me.

Dr. Anderson:
I can't agree more. I'll give you the example I have. As, you know, as a primary care specialist, we get hundreds of documents a week from consults all over, including dermatology. And I recently had a nurse who wanted to know why a lab test hadn't been done that they had requested. But it had been buried in the bottom of page three in one line of a four-page consult note that we got back. And I'm like, ‘Really? You think I read every line of every consult? I'd never see a patient.’ So I can't tell you how important is that we just pick up the phone. And my nurses know, if another physician is on the phone, I stop what I'm doing, and I'm getting out of the room, and I'm going to the phone. Because we're busy people. You're not going to stop and pick up the phone and call me unless it's important. And it's really about the patient and being able to communicate about what their needs are, and being sure that we're all on the same page, isn’t it? So, I mean, you and I are in total agreement about how we work together. Are there any take-home messages that, as a dermatologist with a lot of experience, you would say to a primary care or endocrinologist specialist, about people with diabetes?

Dr. Greenberg:
Yeah, the first thing that I would suggest to my fellow dermatologists is to make yourself aware. Awareness is the first step in anything. And after doing the research and after talking to you, it's going to be in my mind to look out for diabetic changes more than ever. That's the first thing.

Second thing is not to be scared to communicate with an internist and say, ‘Listen, now I think this may be a diabetic issue, why don't you check the patient out,’ rather than just having the patient go back to the doctor and give that message. It's all about communication and awareness.

And taking the time, that's the third thing. Taking the time to get into these problems. Because, you know, honestly, John, in these days when everybody is rushed, and worried about metrics, which I'm not at all, but some doctors are; we have to remember why we're there. We're there to serve our patients. If it takes a few extra minutes to make a phone call to talk to a patient about something. I think that's key.

Dr. Anderson:
Well, thank you. That's all the time we have for today. But I want to thank my fellow host, Dr. Michael Greenberg, for joining me to share his perspective as a dermatologist. Now, Michael, it was great speaking with you today. Thanks.

Dr. Greenberg:
Hey, of course, thanks so much for having me, John. And if listeners want to hear more from me and my dermatology colleagues, they can head on over to DermConsult on ReachMD.

Dr. Anderson:
Thanks, Michael. for ReachMD, I’m Dr. John Anderson. To access this episode and others from our series, visit ReachMD.com/DiabetesDiscourse, where you can Be Part of the Knowledge. Thanks for listening.