Clinical Guidelines Diabetes and the Skin · Perleche. DYM is one of the most commonly accepted systems of categorization used in medical mycology for the clinical diagnosis and treatment

Diabetes and the SkinA Handbook for the Clinic

Authors: Dr Rainer Thiede, Dr Martin Lederle, Prof Rolf Daniels

Jun

e 20

11

5110

11

2nd edition with 8 extra

pages on skin care

Clinical Guidelines

Page 3 Skin Disorders in Diabetes

Page 4 Infections of the Skin

Page 10 Skin Disorders Associated with Diabetes

Page 18 Acute Diabetic Foot Syndrome

Page 27 Clinical Photographs

Page 33 Complications with Diabetes Therapy

Page 35 Skin Care and Diabetes

Page 43 Useful Facts on Cosmetic Ingredients

Page 51 Useful Addresses

Diabetes is not only one of the most common diseases of our time, but one of the most cost-ly to treat. It belongs to the group of so-called diseases of modern civilization (cardiovas-cular disease, obesity, etc.), bet-ter known as Syndrome X, that are considered to be holding our society hostage — their pre-valence having reached epide-mic proportions.

Nearly every diabetic experi-ences characteristic skin pro-blems at some time during the course of the disease. Quite commonly, skin manifestati-ons represent the first indicati-ons of the presence of diabe-tes. This manual introduces the reader to some of the most im-portant skin problems typical to diabetes, with emphasis on the clinical environment, including many informative illustrations. Contained in this book is also a descriptive list of the main in-gredients of skin care products to serve as an easy reference for the reader.

Impressum: © Kirchheim

Kirchheim Publishers, Mainz (2011), 2nd edition

Authors: Dr Rainer Thiede, Dr Martin Lederle, Prof Rolf Daniels

Coordination: Matthias Heinz; Production: Reiner Wolf; Print: Hofmann Infocom, 90411 Nürnberg

Kirchheim + Co GmbHKaiserstrasse 41D-55116 Mainz

Courtesy of neubourg skin care

GmbH & Co. KG.

Clinical Guidelines: Diabetes and the Skin

With this handbook, we wish you pleasant reading and ho-pe to provide you with a practi-cal guide to your daily work in the clinic.

The Authors

Dr Martin Lederle, Diabetologist,

Stadtlohn, Germany.

Dr Rainer Thiede, Dermatologist,

Kevelaer, Germany.

Good Skin at a GlanceCleansing of the skin in people with diabetes should be carried out using pH-neutral preparations. Products containing artificial fragrances, colours and preserva-tives should be avoided as far as possible.

Bathing should be limited, and the ideal water tem-perature should lie between 30° and 35° C. Very hot water should be avoided. Also, showers should be short, using cool water. A soft towel should be used for drying the skin. Wrinkles should be dabbed and not wiped, and skin in crevaces must be dried meti-culously. A linen cloth should be placed under skin folds, such as under the breasts, to prevent the build up of moisture.

In order to avoid mycotic infec-

tions, socks should be changed

daily, and always washed at a

temperature of 60° C.

A moisturizer should be applied regularly with a cream or lotion free of fragrances, colours and preservatives.

The feet need special care and daily inspection. If the mobility of the patient is limited, a telescopic mir-ror can be used. Care of the feet and toenails is in-dispensible, and should be carried out by an experi-enced podiatrist. The shoes should also be regularly checked for foreign particles or defects.

In order to avoid mycotic infections, socks should be changed daily, and always washed at a temperature of 60° C. Studies have shown that boiling the wash-ing is deemed unnecessary as certain fungi are ef-fectively destroyed at a temperature of 60° C. Nylon stockings are a breeding ground for fungi. As ny-lon stockings cannot usually be washed in hot wa-ter, spores can remain in the stockings over a matter of weeks. Going barefoot should also be avoided.

In principle, adequate physical exercise and all-round good metabolic control should be aimed for.

People with diabetes should regularly examine their feet for any problem signs.

Skin

3© Kirchheim-Verlag, Mainz • Clinical Guidelines (2011) • Skin

Skin Disorders in Diabetes

The skin of people with diabetes tends to have a soft and withered consistency. The skin of di-abetics ages and develops wrinkles more rapid-ly. The skin of diabetics is, per se, quite dry and flakes easily.

What it is about the diabetic metabolic state that causes skin disorders is still being debated. It is established, however, that premature age-ing is caused by a slowed function of the sweat and sebaceous glands, a reduction in the skin’s ability to retain moisture, under-developed ke-ratinocytes1 (due to lack of insulin), and reduced cutaneous immunity.

The causes of specific skin disorders lie in circu-latory problems due to micro- and macroangio-pathy, diabetic polyneuropathy with neurolo-gical changes such as sensory disorders, and a weakened immune system.

Skin disorders in people with diabetes are usu-ally categorized into three groups:

1. skin infections,2. skin afflictions typical to diabetes, and3. the diabetic foot.

The skin of people with diabetes is considerably dry.

1Keratinocyte = epidermal cell

Skin

© Kirchheim-Verlag, Mainz • Clinical Guidelines (2011) • Skin 4

Due to their weakened immunity (reduced func-tion of the defence cells and antibody produc-tion), diabetics are considerably more vulnera-ble to mycotic and bacterial infections. Hyper-glycaemia (the epidermal glucose content is 35-65% that of the blood glucose level), neuro-pathy and dry skin also contribute to the skin’s susceptibility. In this way, the diabetic metabolic state is an absolute hotbed for the building of local infections. Lesions are more common and more severe in diabetics than in non-diabetics, and are much harder to heal.

Infections of the Skin

Trichophyton mentagrophytes.

Tinea pedis.

Fortunately, diabetics with well con-trolled metabolic states are at no high-er risk of contracting such skin infec-tions as mentioned here than their non-diabetic peers.

Skin


DermatophytesPathogenic fungi can generally be divided up into three groups according to the DYM system (dermatophytes, yeasts, moulds, see page 7). Dermatophytes are mainly responsible for fun-gal infections on the feet and legs, as well as on

Onychomycoses.

Tinea corporis.

Moist, macerated areas must be kept dry. An association between a poor di-abetes control and the development of mycoses has long been established. A well controlled metabolic state is, therefore, the best prophylaxis.

the body, and are mostly made up of microbes called trichophyton rubrum and trichophyton mentagrophytes. It usually manifests first and foremost between the toes, especially between the fourth and fifth (interdigital mycosis). White-coloured fissures or fine lamellar scaling first ap-pear that can eventually spread across the whole foot (tinea pedis).

From its focal point, tinea develops centrifugally as a sharply demarcated area of flaky skin. The difference between an outbreak of tinea pedis

Fungal Infections of the Skin

Skin


Candida infections.

and extremely dry skin is often not possible with-out the help of a mycological diagnosis. Myco-sis is not to be taken lightly in the case of dia-betics. On the one hand, the tiny fissures in the skin provide an opening for streptococci, that can lead to erysepelas. On the other hand, inter-digital mycosis, if left untreated, can spread to the toenails (onychomycosis). This condition can also form a reservoir for pathogens which can be scattered around with every change of socks or stockings. Hence, tinea corporis can spread across the entire integumentary system.

Antimycotic creams must not be used prior to a clinical diagnosis of fungal infections. This ap-plies also to the nails, as many people can buy an array of antimycotics over-the-counter and try home treatment prior to seeing a physician. A six-week time lapse without therapy must be

adhered to before a sample is taken for exam-ination.

The sample should be taken towards the outer edge of the skin or nail infection. With myco-sis of the nails, the sample should be taken sub-ungual, i.e., from under the nail. Because the dermatophytes grow very slowly, it can take as long as six weeks for a conclusive result to be obtained from the culture.

Treatment of fungal infections usually consists of topical administration of antimycotics. If the infection is particularly therapy resistant, or af-flicts the whole body, systemic treatments are preferred.

Skin


YeastsYeast colonies are usually found on areas of the body where skin meets skin, leading to an oc-clusive effect. It is in such moist environments that yeasts thrive. Ideal locations are, for exam-ple, under the breasts, under the arms, the groin region, the corners of the mouth (perleche), in-side the mouth, and genitals.

It is important that the fungal infection is not treated with any antimy cotic ap-plications before being diagnosed. This applies also to the nails, as many pa-tients treat their skin and nails with an array of over-the-counter medica-tions beforehand.

Tinea corporis. Perleche.

DYM is one of the most commonly accepted systems of categorization used in medical mycology for the clinical diagnosis and treatment of mycoses. This table presents a sample of pathological fungi using the DYM system.

D Y M

Trichophyton Candida albicans Aspergillus fumigatus

T. mentagrophytes C. tropicalis A. niger

T. verrucosium C. glabrata Scopulatiopsis species

Microsporum canis Trichosporon species Cephalosporium species

M. gypseum Rhodotorula species

M. audouinii Cryptococcus species

Epidermophyton floccosum Pitrosporum species

DYM: Dermatophytes – Yeasts – Moulds

Skin


Bacterial Infections

ErysipelasErysipelas appears as an extensive rash. The point of outbreak is usually some kind of skin defect such as a discreet case of interdigital my-cosis between the toes that serves as point of entry for streptococcal bacteria. The strepto-cocci penetrate the injury and spread across the skin, manifesting in the classic clinical symptoms of an area of sharply demarcated redness. Fur-

Erysipelas associated with the diabetic foot.

ther to this, the patients often complain of fe-ver and chills. It is more difficult to diagnose re-curring erysipelas, as the clinical symptoms are less obvious; fever and chills are hardly discern-able. It is best to avoid a recurrence of erysip-elas if at all possible, as repeated infections in the vessels can cause adhesions which can lead to lymphoedema.

Penicillin is and always has been the preferred treatment for erysipelas. The affected region should be rested. San-itization of the point of entry contrib-utes considerably to therapeutical suc-cess and helps to prevent recurrence.

Skin


Abscesses, furuncles, carbunclesThese bacterial skin infections are fluctuant, caused mainly by staphylococci, and usually start out in a hair follicle. They can be treated operatively (according to the adage often cit-ed in medicine, “ubi pus ibi evacua” = “where there is pus, there evacuate it”), or systemically with antibiotics on the basis of an antibiogram.

A rarity, but exclusive to people with diabetes, is malignant otitis externa. It is triggered by pseudomonas aeru-ginosa. The diagnosis is reached by means of bacterial culture. It is treated systemically--according to the results of an antibiogram--with antibiotics.

Skin


Necrobiosis lipoidicaNecrobiosis lipoidica is an inflammatory reaction that tends to appear on the shins. In rare cases, the arch of the foot is afflicted. Cases have been reported on other parts of the body, but this is considered exceptional. It appears as a pretibi-al2, sharply demarcated, rough, yellowy-red ef-florescence3, that can spread centrifugally to saucer size. In its centre, the skin becomes thin and tiny blood vessels appear (teleangiectasia). The skin in the centre becomes more and more fragile until--as occurs in around one-third of the cases--ulceration appears within the necro-biosis lipoidica. Some sort of injury to the area is usually responsible for triggering the ulceration.

Necrobiosis lipoidica is treated mainly with com-pression therapy, nicotine abstinence, protection from injury, as well as a stage-adapted wound care. Steroids administered locally or intrafocal-

Skin Disorders Associated with Diabetes

Necrobiosis lipoidica occurs three times more frequently in women than in men.

ly4 offer a further mode of treatment. In gener-al, necrobiosis lipoidica is difficult to treat, even when there is no connection to diabetes.

Necrobiosis lipoidica.

Pruritus diabeticorumItching is a common symptom amongst diabet-ics, especially on the feet, lower limbs, as well as on the back. Even in non-diabetics, increas-ing age causes a physiological regression of the gland function in the lower limbs, causing dry skin. This leads to the development of asteatotic eczema. The flakey scales on the surface of the skin, that look like badly laid paving stones, ir-ritate the underlying nerve endings. This trig-gers itching, the patient scratches himself, and so a vicious cycle begins.

Being so therapy resistant, vulvovaginal itching is a case in itself where the patient is often sent on a lengthy odyssey that can end up in the di-agnosis of diabetes. In this way, insistent vulvo-

2pretibial = on the shin3efflorescence = skin eruption4intrafocal = within a wound

Skin


Pruritus with eczema. Pruritus diabeticorum.

A correlation between pruritus diabeti-corum and the diabetic metabolic state has not been established. Optimal dia-betes control does not necessarily ac-celerate the healing process.

Perforating dermatosisIn this condition, hyperkeratosic papules and nodules appear, partly umbilicated and, as a rule, lineally arranged. This skin disorder is found mainly on the extensor sides of the lower ex-tremities. It is often accompanied by itching.

Diabetic dermopathyDiabetic dermopathy (shin spots) appears in around 15% of diabetics. These reddish-brown spots are asymptomatic and slightly atrophic. They usually heal after a few years without leav-ing scars.

Acanthosis nigricans benignaAcanthosis nigricans benigna manifests as a patch of hyperkeratotic, velvety brown, which appears on the neck, the armpits, or the groin. It normally neither hurts nor itches. As it appears like a patch of dirt, the patients sometimes find their way into the clinic because they were un-able to ‘wash’ this patch of dirt off. This condi-tion is present in around 90% of young type 2

vaginal itching can actually be an indication of undiagnosed diabetes.

Prurigo diabeticorumIf the aforementioned pruritus diabeticorum is left unattended, it can cause the patient to have severe scratching attacks. This scratching leads to the development of pruritic nodules (prurigo nodularis), which can become as big as a pea, and are found in the areas of the body acces-sible to the patient. This observation is impor-tant in the clinical diagnosis of this condition, as the symptoms are very similar to the ever-increasing disease of scabies, the only differ-ence being that in scabies, the symptoms ap-pear also in bodily areas that are not accessible to the patient.

Skin


Diabetic dermopathy.

Acanthosis nigricans.

diabetics, and also in overweight youths. Clin-ically, it is important to eliminate the presence of acanthosis nigricans maligna, which can be an indication of stomach tumour, namely, ade-nocarcinoma of the bowel. This form is identifi-able by the rapid proliferation of the skin anom-aly, as well as a palmoplantar and/or mucocuta-neous manifestation.

Topical therapy with retinoic acid is worth trying in the treatment of acan-thosis nigricans. However, losing and maintaining normal weight has prov-en to be the most effective approach.

Skin


Cheiroarthropathy diabeticorum

Cheiroarthropathy diabeticorum is character-ized by a painless stiffening of the hands and fingers, limiting their movement. Usually, both hands are afflicted at the same time, and the symptoms symmetrical. Due to the stiffness, the hands can no longer be stretched out flat. This is why this condition is sometimes named as the ‘prayer sign’ or ‘table top sign’. A specific ther-

Patients with the ‘prayer sign’ are 10 times as likely to suffer from retinopathy, cardiovascular disease and nephropathy.

fects mostly elderly diabetics who have had di-abetes over a long period of time. However, in severe cases, a hardening of the thorax can oc-cur, whereby the patient has massive trouble breathing. Hence, it is important that physio-therapy be prescribed early on.

Other forms of scleroedema diabeticorum should be eliminated that, for example, occur as a result of acute infection (scleroedema adul-torum of Buschke).

Bullosis diabeticorumThese diabetic non-itching and painless blisters appear spontaneously and mostly on the wrists and arches of the feet. They are filled with clear fluid. Typically, the surrounding skin is healthy and unaffected. Recommended treatment is to aspire the blisters using a sterile technique, whilst keeping the blister intact as a natural pro-tective cover. Specific therapy is unnecessary, as

Bullosis diabeticorum.

apy for this disorder is not known. Physiother-apy is usually prescribed.

Scleroedema adultorumScleroedema adultorum is known as a condition where non-itching, painless swelling and indu-rations appear on the neck, as well as on the back. In time, this efflorescence can spread to the face and chest, and to the entire back. The skin appears as orange peel. This condition af-

Skin


the condition is self-limiting and heals usually within a matter of weeks, scar free. An associa-tion between bullosis diabeticorum and the met-abolic state has not been able to be detected. It may be triggered by microinjury, or by light.

Palmar erythaema

Palmar erythaema appears similar to rubeosis faciei, except that the flushing occurs on the inside of the hands instead of on the face. The flushing appears mainly on the thumbs and pads of the little fingers. Although this anomaly ap-pears frequently in people with diabetes, it is al-so associated with an array of other underlying conditions such as heart failure, hepato pathy, hyperthyreosis, pregnancy, malnutrition, colitis ulcerosa, etc., and is therefore not considered diabetes-specific.

Psoriasis vulgarisRecent studies emanating from England have found that psoriasis vulgaris manifests two-to-three times more frequently in diabetics than in their non-diabetic peers. The correlation was more pronounced with increased severity. It has been established, in recent years, that psoria-sis vulgaris represents an inflammatory disease. Patients with this condition tend to suffer from the classic risk factors such as lipidaemia, high blood pressure and overweight. These risk fac-tors are known as syndrome X, and are consid-ered to be the main contributors in the devel-opment of arteriosclerosis. This inflammatory process triggers the release of substances that hinder the insulin effect on the cells. Thus, with time, this insulin resistance develops into fully-fledged diabetes.

Psoriasis vulgaris is characterized by well de-fined, flaky, silvery plaques, that appear on the scalp and behind the ears, on the elbows, on the knees, under the breasts and around the anus (on these atypical places, the psoriasis is named psoriasis inversa). The diagnosis of psori-asis vulgaris is usually carried out by anamneses and clinical findings. The condition is genetic.

As bullosis diabeticorum is diagnosed by exclusion, it is important to elimi-nate other blister-forming diseases, es-pecially if they appear on parts of the body other than the hands and feet, as this is where bullosis diabeticorum tends to localize.

Eruptive xanthomasEruptive xanthomas are crops of millimetric, yel-lowish-red, soft, fatty deposits in the skin. They usually appear symmetrically on the extensor sides of the extremities. Itching is rare. Their appearance seems to correlate with hyperlip-idaemia.

Treatment of eruptive xanthomas involves sta-bilizing the underlying diabetic hyperlipidaemic state either with dietary measures or medicinal-ly. In this way, the depositions should disappear within a matter of months. If the eruptions fail to heal, or are cosmetically disturbing, operative treatment should be considered. Very favour-able results have been achieved using ablative lasers such as CO2 or Erbium-Yag laser devices.

Rubeosis facieiAppearing frequently in diabetics, but not di-abetes-specific, is rubeosis faciei, which mani-fests as flushing on the face which can, under certain circumstances, spread to the shoulders and arms. The flushing can also be accompanied by oedematous swelling.

Skin


Psoriasis vulgaris.

Fibroma pendulansIndividual studies have shown a correlation be-tween the presence of fibroma pendulans and diabetes. This condition describes skin-coloured, shaft-like or wart-like skin tags that mainly ap-

pear on the eyelids, the neck, under the arms, and in the groin region. These growths are com-pletely harmless, but are considered a nuisance by most patients. They can be removed by a sim-ple surgical procedure.

ErythromelalgiaErythromelalgia is an incidental condition, char-acterized by areas of red, painful, and burning skin. Besides cooling, there is no specific therapy.

Palmar erythaema.

Patients with psoriasis vulgaris tend to suffer from the classic risk fac-tors: lipidaemia, high blood pressure, overweight.

Skin


Fibroma pendulans.

Granuloma annulare disseminatum

Granuloma annulare disseminatum is a ringed, mostly skin-coloured group of nodules with sunken centres. This condition is asymptomat-ic, and mainly appears on the back of the hands and feet. In diabetics, one usually finds sever-al outbreaks.

In 75% of the cases, the condition heals by it-self within two years. Further therapeutical op-tions are topical steroids as well as photothera-py (PUVA-psoralen and UVA therapy).

Skin


Granuloma annulare.

Diabetic Foot Syndrome

18 © Kirchheim-Verlag, Mainz • Clinical Guidelines (2011) • Skin

Diabetes: A Disease of Modern Civiliza-tion

In 2006, an estimated 7.1 million people were living in Germany with diagnosed diabetes. Not all people with diabetes suffer from diabetic foot. This figure lies somewhere between 2% and 7%.

What is Diabetic Foot?

Diabetic foot refers to a lesion, injury, or disorder that occurs beneath the knee joint in people with diabetes, which can take the following forms:

– an acute lesion (pressure ulcer, infected wound, callus haematoma),

– a chronic wound (over six weeks) with no healing tendency,

Acute Diabetic Foot SyndromeCauses, Diagnosis and Therapy

– a diabetic neuropathic osteoarthropathy (DNOAP) with at least two clinical signs ( heat, swelling, pain, redness) or a radiological finding, or

– a postamputative condition with vulnerable stump or extremely tender scar from a healed ulcer.

Diabetic foot syndrome appears amid the context of diabetic neuropathy and/or venous insufficiency in the legs.

According to a Statuary Health Insureancefund report (Wissenschaftliches Institut der Ortskrankenkassen), 32,000 people with diabetes underwent minor amputations (below the ankle) and major amputations (above the ankle) in Germany in the year 2003.

People with diabetes are highly vulnerable for the following reasons:

– The rate of recurrence for a foot lesion is very high: Around 70% of patients suffer from a new foot lesion within five years.

– Around 50% of patients that have undergone an amputation due to the diabetic foot syndrome will require another one on the other limb within four years.

– Over 70% of patients are unable to return home after having undergone a foot amputation.

– Around 50% of patients die within three years of undergoing an amputation.

Despite the above, it has also been established that, with early intervention and proper treatment, at least 50% of amputations can be prevented.

Incidence of diabetes-related con-ditions that can lead to the diabetic foot syndrome:

Diabetic Neuropathy approx. 50 %

Arterial Insufficiency approx. 15 %

Combination approx. 35 %

Diabetic Microangiopathy5 plays no role in the development of foot le-sions.

5 Diabetic microangiopathy = changes of the small arte-ries, which are clearly revealed by histological examinati-on. Diabetic microangiopathy is responsible for diabetic retinopathy = changes in the retina, and diabetic nephro-pathy = changes in the kidneys.



Diabetic neuropathy

Diabetic neuropathy is the result of long-term (over months to years), chronic hyperglycaemia which, over time, leads to nerve damage.

In the foot, all nerve types (motor, sensory, au-tonomic) can be affected.

▶ An additional amputation on the right foot

After the patient had already lost part of the right foot due to diabetic foot syndrome, the ap-pearance of another deep lesion on the sole in the presence of diabetic neuropathy led to a com-plete foot amputation.

Types of Podiatric Diabetic Neuropa-thy:

Motoric Neuropathy: atrophy of the small muscles of the feet; plantar subluxation of the heads of the me-tatarsal bones; the toes are drawn towards the arch of the foot

Sensory Neuropathy: reduced sensiti-vity to pain

Autonomic Neuropathy: reduced per-spiration

A typical feature of diabetic neuropathy: The heads of the metatarsal bones sublu-xate towards the sole, drawing the toes toward the arch of the foot.

▶ Diabetic Neuropathy



The changes that occur due to diabetic neuro-pathy can alter its gait on walking, that is, the way the foot rolls6. The balls of the big toe and the little toe bear more of the burden, and the middle toes less. Due to this increase in load, the affected areas develop a thickening and harde-ning of the outer skin layer (hyperkeratosis7).

Limited joint mobility

Due to the build-up of glucose in the podiatric connective tissue, it becomes thickened and har-dened, the result of which is a phenomenon called claw toe. Due to the extra pressure with each step, this condition can cause hyperkera-tosis on the tip of the affected toe.

▶ Hyperkeratosis on the tip of the left big toe.

The left foot of the patient is longer than the right foot. If the shoes are the same size, the tip of the left big toe chafes on the inner lining of the left shoe, resulting in ad-aptive hyperkeratosis.

In the above illustrations, one can see that the claw toe on the right foot extends plantarical-ly beyond the other toes. The constant pressu-

A hooked big toe.

Hooked toe with hyperkeratosis.

re on the tip of this toe, with each step, has led to hyperkeratosis with a central lesion.

Neuropathic complaints

Some people with nerve damage in the feet due to diabetic neuropathy do not feel any symptoms. Others may have symptoms such as tingling, pins and needles, burning, pain, etc. or numbness--loss of feeling--in the hands, arms, feet, and legs, which are more pronounced du-ring the night. This affects the patient signifi-cantly and greatly disrupts well-being.

6 Normal rolling of the foot = When walking, the foot rolls from the heel to the metatarsal bones and kicks off with the toes.7 Normal skin always reacts to increased pressure and constant chafing in the same manner: it forms localized hyperkeratosis.



1. A callus is formed 2. Subcutaneous haemorrhaging

3. Ulceration of the skin 4. Deep infection with osteomyelitis

Illustration of ulcer formation due to excess pressure.

Special Manifestations of Diabetic Neuropathy

Septic thrombosis

If a neuropathic lesion forms under the head of the first os metatarsale8, bacteria can make their way in to the soft tissue and spread until they reach the digital artery of the big toe. In-fections in this region can lead to a thrombo-

1. Keratosis develops at the location on the sole of the foot that is exposed to excess pressure. A callus is formed.

2. The callus presses into the sensitive con-nective tissue underneath like a small stone and causes a haemorrhage.

3. The hyperkeratosis becomes brittle and splits. Bacteria are able to penetrate in-

to the connective tissue. The callus opens up, forming an ulcer.

4. The bacteria can enter the deep lying tis-sue via the lesion, resulting in ostitis that can involve the joint.

▶ Diabetic foot syndrome: from hyperkeratosis to ulcers

sis which blocks the artery. As a result, the sur-rounding tissue cannot be adequately supplied with oxygen, and it becomes necrotic. The toe blackens, even though the blood supply to the rest of the foot is normal.

Septic thrombosis, with subsequent tissue ne-crosis, is caused by diabetic neuropathy. If the

8Os metatarsale = metatarsal bone



▶ Stages of septic thrombosis

Photo 1: The patient, by wearing shoes that were too small, contracted a lesion on the medi-al side of the left 2nd toe.

Photo 2: The infection spreads until it reaches the toe’s digital artery. Necrosis of the tissue re-sults, leaving the bone exposed.

Photo 3: The ischaemic tissue mummifies; the toe is unsalvable.

Photo 4: Situation following resection of the 2nd

toe. In the presence of good arterial perfusion, the amputation bed heals flawlessly.



background of such a condition is not considered carefully enough, it may be mistakenly seen as an indication for too high an amputation, as the arterial perfusion is otherwise quite normal.

Diabetic neuropathic osteoarthropathy (DNOAP) or Charcot Joint Disease

DNOAP is a non-bacterial inflammatory conditi-on located in the vicinity of the tarsal bone and the surrounding soft tissue. The affected foot swells and becomes considerably over-heated. This condition is not usually accompanied by a cutaneous wound. Unless the foot is disencum-bered, microfractures in the bone can result, leading to a permanently and fully deformed arch of the foot.

Treating acute DNOAP

The affected foot must be placed in a lower-leg orthesis until the inflammation has com-pletely subsided.

The clinical picture of DNOAP is unfamiliar to many doctors and is thus falsely treated--even to the point of recommending amputation.

▶ Diabetic neuropathic osteoarthro-pathy (DNOAP)

The patient was suffering from painful swel-ling and overheating of the right foot. Lymph drainage was carried out to alleviate the lym-phoedema. The patient continued to burden the right foot. After a period of six weeks, the arch of the foot had considerably altered.

The right arch of the foot had completely flattened.

Orthesis of the lower leg.

Arterial insufficiency

Patients with diabetes tend to develop clogging of the arteries in the lower leg, reducing the blood flow in that area. A typical example of the symptoms of a severe case is a condition named Claudicatio intermittens--otherwise known as the window-shopping-disease.



The regions suffering from lack of blood supply (mainly the toes and heels) are particularly vul-nerable to pressure, whereby lesions can appear at the slightest injury, which are difficult to heal.

As these ischaemic ulcerations usually start ve-ry small, their severity is often underestimated.

▶ Arterial insufficiency

In the presence of arterial insufficiency, the visible lesion on the surface of the skin often represents just the ’tip of the iceberg‘.

▶ Hyperkeratosis

Hyperkeratosis on the outer side of the little toe (Os metatarsale 5).

After debriding the surface of the callus, one can see that the underlying lesion has reached as far as the bone.

However, these particular wounds can only heal when the blood supply in the surrounding area is enhanced. Hence, local treatment for this con-dition is pointless.



Conclusion

In the treatment of diabetic foot syndrome, the underlying cause of the disease should be cla-rified before initiating any therapeutical mea-sures. First and foremost, the presence of arteri-al insufficiency must either be conclusively con-firmed or ruled out.

The type of therapy will depend upon this im-portant diagnostic step.

Differentiating between diabetic neuro-pathy and arterial insufficiency

The main feature of the presence of both dia-betic neuropathy and arterial insufficiency is the absence of sensation. Due to the nerve damage, even a severe ischaemic wound causes no pain in the affected muscle. As a result, the severity of the arterial insufficiency is easily overlooked.

The discernment between diabe-tic neuropathy and arterial insuffici-ency, which often needs to be done using technical diagnostics, is of ut-most importance.

Further factors that exacerbate diabetic foot syn-drome are: – chronic venous insufficiency and varicose veins – lymphoedema – visual impairment – neurological disorders such as paresis of foot elevation following apoplexy

Treating a diabetic neuropathic foot lesion in-volves: – complete pressure relief for the affected area – systemic antibiotics (depending on the size of the lesion)

– optimization of blood glucose levels

Treatment of arterially insufficient lesions

First: – carry out interventional measures to correct the arterial insufficiency

Then: – completely relieve the affected area of pres-sure

– administer systemic antibiotics (depending on the size of the lesion)

– optimize blood glucose levels

Neuropathy PAD

skindry, warm, pink, varicosis even at 30°C and raised, with no change of colour

atrophic, thin, cool, pallid, and relief when forefoot is raised

tissue oedema frequently detectable oedema rare

hyperkeratosispronounced on pressure points, splits on the heels

slowed growth, sand-papery hyperkera-tosis

nails mycosis, subungual bleeding thickened, hyperonychia

toes clawed/hammer toes, corns no hair, pallid, acral lesions

arch of the foot atrophy of the Mm. interossei general atrophy

sole hyperkeratosis, rhagades, pressure ulcers skin removable in folds

How to differentiate between neuropathy and peripheral arterial occlusive disease.



Wagner-Stage ▶0 1 2 3 4 5Armstrong-

Stage ▼

A pre- or post-ulcerated

foot

shallow wound

wound reaches

tendon or capsule

deep wound reaching bo-ne and joint

necrosis on parts of foot

necrosis on entire foot

B w/ infection w/ infection w/ infection w/ infection w/ infection w/ infection

C w/ ischaemia w/ ischaemia w/ ischaemia w/ ischaemia w/ ischaemia w/ ischaemia

D infection and

ischaemia

infection and

ischaemia

infection and

ischaemia

infection and

ischaemia

infection and

ischaemia

infection and

ischaemia

Descriptions of the diabetic foot syndrome using the Wagner-Armstrong method of classification.

In planning for a stage-oriented mode of treat-ment, the size of the lesion must be accurate-ly determined. The Wagner-Armstrong wound classification method is designed for this pur-pose (see Table).

The most common cause of foot lesions is the wea-ring of shoes that are too small.

The Specialized Diabetes Practice


The Specialized Diabetes Practice: Clinical PhotographsSkin Disorders in Diabetes

When treating people with the diabetic foot, I am often confronted with skin disorders not neces-sarily directly related to the condition. Time and again I see conditions that are not able to be deci-phered with diabetological competence alone. In cases such as these, I confer with a dermatologist.

1. Patient with mycosis of the toenails

Patients with badly controlled diabetes often suffer from mycosis of the toenails. Treatment can only be successful when the blood glucose is stabilized. The use of local therapeutical mea-sures such as nail polishes containing antimyco-tic substances are usually ineffective.

2. Patient with mycosis on the soles of the feet

Fairly typical of my-cosis of the sole is the relatively sharply de-fined redness under the foot (‘moccassin‘ disorder). Effective treatment of this con-dition must include the socks and shoes.



3. Ingrown toenails

The pressure of the brittle toenail in the nail wall can cause a very painful infection of the nail bed = panaritium.

4. Severe infection of the nail bed with protruding granulatory tissue

Nail bed infections of the big toes on both feet.

5. Neglect

Protruding, brittle toenails can injure neighbouring toes.



6. Oedema of the lower leg: danger of injury due to tight socks

7. Skin disorders with chronic venous insufficiency

On the right lower leg of this patient, one can see a severe trophic skin disorder with post-thrombotic syndrome. The skin is so fragile that even the constant contact with the inside of the trousers can cause a lesion to appear on the sur-face of the skin.

8. Patient with Klippel-Trenaunay Syndrome

Klippel-Trenaunay Syndrome is a congenital abnormality affecting the soft tissues and blood vessels. Here, the patient’s left lower leg and foot is seriously afflicted. She eventually decided to have the lo-wer limb amputated.



9. Varicose Ulcer Cruris

10. Plantar Warts

A plantar wart on the ball of the foot. A large plantar wart under the heel following many attempts at healing.

Due to venous insufficiency, the skin and the un-derlying tissue become frail and liable to deve-lop deep chronic wounds.



11. Petechiae skin purpura

Petechiae describes round spots that appear on the skin as a result of subcutaneous bleeding. This picture illustrates a case on the lower leg.

The abdomen of the same patient.

Explanation: This patient was treated with antibiotics because of diabetic foot. As a result, bacte-rial colitis developed manifesting as petechiae.

12. Foreign body following surgery

On the medial side of the left head of the 1st

metatarsal bone of this patient, a lesion deve-loped containing a hard object.

The object was removed with tweezers. Years before, the patient had undergone surgery on the left foot. The surgeon had implanted an an-tibiotic chain. With time, one of the links of this chain had made its way to the surface.



13. Venostatis dermatosis on the lower leg

14. Widespread hyperkeratosis on the sole

This patient was ope-rated on the forefoot, after he wore shoes whose inlays were no longer effective.

Complications


Complications with Diabetes Therapy

Adverse Reactions to Medication

Oral antidiabetics rarely trigger allergic re-actions. The reaction shown here involved maculopapular efflorescence which spread over the whole body, especially on the trunk. Reactions such as these appear somewhat like measles or chickenpox and are usually accom-panied by a general feeling of ill-being. The pa-tient recovers as soon as the medication in ques-tion is stopped.

Sulfonylureas (not to be confused with urea) tend to be associated with increased photosen-sitivity. Hence, patients taking such medications are more vulnerable to getting burnt when out

in the sun. This is particularly true as people with diabetes tend to prefer sugar substitutes, such as cyclamate or aspartame, which also raise the skin’s sensitivity to light.

Insulin AllergyThere are two different types of insulin al-lergy. One involves a local allergic reaction, and the other involves a generalized reac-tion which takes the form of exanthema (sud-den rash), or other unspecific symptoms such as itching, wheals, or erythema. Local infec-tions involve redness, wheals and/or nod-ules that appear around the injection site. Whether or not one is at risk for developing

Adverse reaction to medication.

Complications


an allergy is usually genetic. Patients known to have an allergy to penicillin are statistical-ly more likely to develop an allergy to insulin. Generalized allergic reactions are rare indeed. This usually manifests as exanthema, but urticaria with angiooedema has also been known to occur. If you have cause to suspect the development of an insulin allergy, an allergologist should be consulted to carry out a conclusive diagnosis.

Insulin LipodystrophyInsulin lipodystrophy is a rare side effect of insu-lin administration, whereby the skin and the un-derlying tissue thins out or granulates at the in-jection site. This condition affects mostly women and children, and usually appears six months to two years after commencement of therapy. Fortu-nately, this anomaly tends to disappear by itself.

In any case, the injection site should be changed. Local complications such as this tend to appear more often with animal insulin of sub-quality. However, due to the modern-day usage of ge-netically engineered insulins, this problem has lessened considerably.

Insulin lipodystrophy.

Skin Care


Approximately 80% of people with diabetes suf-fer from some kind of skin problem as a con-sequence of high blood sugar levels. Typical symptoms are extreme dryness (xerosis, xero-dermatitis), calluses, pressure ulcers and cracks on the feet, itchiness, skin infections and sores. The sweat and subaceous glands often fail to work properly, leaving the skin without an ad-equate supply of oil and moisture. Thus, the skin rapidly becomes rough and scaly. This problem is most visible on the legs and the feet, and is usually accompanied by itching. Dry skin re-acts to external chemical and physical haz-ards more easily than normal skin. Bacteria, moulds, allergens and poisons can enter the skin more easily and cause irritations. In ad-dition, the dry skin is exacerbated by the fact that lack of insulin disrupts the differentiation of the keratinocytes, damaging the skin barrier. Diabetes therapy must, therefore, include an appropriate skin care regimen. The purpose of skin care products is to replenish the skin’s mois-ture and fat content, as well as to create a pro-tective layer against the outside environment.

Skin Care and Diabetes

Extra-cellular lipids in the keratinous layer

Fig.1: Schematic diagram of the skin barrier.

A Defensive Shield

The most important function of the skin is to create an effective barrier between the organ-ism and the environment. The outer layer (epi-dermis) forms a physical, chemical/biological and an adaptive immunological line of defence. The physical barrier function is carried out by the horny layer of the skin (Stratum corneum), the outermost layer of the epidermis, made up of a physical and molecular weaving of the cells (cor-neocytes) as well as the double layered sheet of stratum-corneum lipids (see Fig. 1).

A method of assessing the health of the outer layer of the skin and the effectiveness skin care products have had, is the measurement of trans-epidermal water loss (TEWL). Here, the evapo-ration of the water that passes through the epi-dermis is measured on a particular area of the

Corneocyte

Living Epidermis

Fig. 1a: Transepidermal Water Loss (TEWL) is a method for assessing the barrier function by mea-suring the skin’s rate of transpiration.

Transepidermal Water Loss (TEWL)

Transpiration

Skin Care


skin over a particular time. The rate of TEWL increases in proportion to the level of damage to the cutaneous barrier. Hence, a reduction in TEWL signifies a reconstitution (Fig. 1a).

Systematics of External Preparations

Caring for dry skin can be done using different kinds of external formulas. A systematic catego-rization can be taken from the phase-triangle used in dermatology to illustrate the effect dif-ferent types of formulas have on the skin and how they are absorbed (Fig. 2).

The type of formula used depends on the severity of the dermatosis, and the sever-ity of the damage to the skin. A gener-al rule of thumb: wet-on-wet and fat-on-dry. If this guideline is overlooked, and the wrong

Hydrogel Lotion Cream CreSa Ointment Fatty cream

Fig. 2: Triangle illustrating the various combinations of bases.

PastesTalcum,

Zinc oxide

FatFats, Oils,

Waxes

LiquidAlcohol,

water, aque-ous solutions

Suspension (Lotion)

Powder

Pasten

type of formulation cooling greasy hydrative occlusive rinses off

hydrolotions + + +(+) - +

lipolotions - ++(+) ++ ++ -

creams + + +(+) + +

thick creams/ointments - ++(+) ++ ++ -(-)

Table 1: Skin care products and their intended effects.

type of product used, this can inflict further damage to the skin barrier.

Most products used in the care of dry skin are manufactured as liquid or spreadable emulsions. These can be divided up into four different bas-es (Fig. 2a):

• Hydrolotions: liquid oil-in-water emulsions• Lipolotions: liquid water-in-oil emulsions• Creams: spreadable oil-in-water emulsions• Fatty creams: spreadable water-in-oil emul-

sionsThe ways in which these traditional formulas af-fect the skin is summarized in Table 1.

In order to keep the lotions and creams stable, an emulsifier is added that not only lengthens the shelf-life of the product but also improves its texture. These emulsifiers belong, in their physical attributes and chemical behaviour, to the class of surfactants. They are built like an

O/W-Emulsion W/O-Emulsion

Oil Water Water Oil

Fig. 2a: The two different kinds of emulsions: oil-in-water to form lotions and creams, and water-in-oil to form lipolotions, fatty creams and ointments.

Skin Care


Fig. 3: Lipid structure of the skin barrier; (a) proper lamellar formation, (b) structural disorder and emulsifica-tion through hydrophilic surfactants.

(a) (b)

amphiphile with a hyprophile and lipophile mo-lecular structure, and form bonds, for example, micelles or lamellar liquid crystals (Fig. 4). Due to their surface-active properties, emulsifiers in-teract in many different ways with the skin bar-rier, especially with the lipids in the horny layer. In particular, the water-soluble, hydrophile sur-factants, responsible for stabilizing oil-in-water bases, can actually emulsify the lipids on the skin and adversely affect its barrier function when applied in large amounts (Fig. 3).

Classifying skin care products merely by their water and lipid content is, however, too simple. Only by knowing the types of emulsifiers con-tained in them can you ascertain whether they are based on a water-in-oil or an oil-in-water formular. For instance, a base with 60% water and comparable fat content can, with a hydro-philic emulsifier, become an oil-in-water formu-la, whereas if a lipophilic emulsifier is used, it becomes a more easily spreadable water-in-oil cream. In other words, bases with around the same content of water and oil can, depending on the type of emulsifier used, have a profound-

ly different effect on dry skin, even if they share similar consistencies.

Mousses

Mousses contain gas in a continuous-liquid or semi-liquid form. Depending on how the gas is dispersed, balls of foam or polyederfoam are formed, within which the single bubbles of gas are separated by microscopic lamelles (Fig. 6). Mousses are manufactured by compressing the liquid or semi-solid formula into a pressurized

When treatments work best

Care products work best directly af-ter the skin has been washed. The skin should be dried, with no water remaining on the surface. In this way, skin care products are easier to apply and more easily absorbed.

Skin Care


Water state

Water state

Oil state

AerosolOil state

+Aerosol

(a) (b)

Fig. 5: Schematic illustration of the structure or mousse in a pressurized can before (a) and after (b) release.

container and topping it up with aerosol. Due to this process, mousses are also named foam aerosols, to which the foam creams also be-long. The latter is made with an oil-in-water emulsion combined with an oil-soluble aero-sol. When used, the emulsion exits the contain-er through a small valve at the top and, due to the sudden evaporation, forms a foam. In oth-er words, the foam is formed only on applica-

tion (Fig. 5). The most commonly used aerosols in mousses are propane gas, butane and isobu-tane gas or, albeit very rarely, dinitrogen mon-oxide (laughing gas).

Larger Surface Area, Better Evaporation

The foaming action of an oil-in-water emulsion creates a very large surface area from which vol-

hydrophile lipophile

Tenside molecule Micelle Lamellar liquid crystal

Fig. 4: Schematic illustration of a tenside molecule, a micelle, and lamellar liquid crystal.

Skin Care


atile substances, such as water, can evaporate much faster than from creams. When applied, the preparation of the mousse, once it’s on the skin, shows very little similarity to that which was in the container prior to application. In oth-er words, the watery solution in the can turns into a fatty cream when applied to the skin. This makes it easy to apply whilst keeping the positive effects of a lipid-rich preparation once on the skin.

Hygienically Dosed and Efficient

Apart from the cosmetic aspects, mousses have other advantages over conventional forms of application such as lotions and creams. They can be hygienically and accurately dosed, and

are protected from contamination. In this way, the use of preservatives can often be spared. The air-tight aerosol container, impermeable to light, halts the effects of oxidation and pro-tects light-sensitive substances. A foam can be applied evenly without having to touch the af-fected area, and is quickly absorbed. Thus, due to their ease of application, foams are suitable for wounds or infected skin, for babies and children, and difficult-to-access areas such as between the toes.

Bath Oils

Also part of the skin care regime is the use of bath oils, which can be classified into two groups: dispersing bath oils and soluble bath oils (Figs. 7 and 8). Bath oils contain lipids (e.g., soy oil, olive oil, almond oil, paraffin) that re-main as a thin film on the skin after you get out of the bath. The most effective substances for this purpose are dispersing bath oils. These dif-fer from the soluble bath oils in that they con-tain very little or no emulsifying agents. The oil floats on the top of the bath, and clings to the skin as you get out (as well as on the bath tub). However, this fatty film may smear any clothing you put on afterwards. After such a bath, you

Fig. 8: Pure oil in water produces an oily bath with fat globules that are unevenly dispersed onto the skin.

Fig. 7: Types of bath oils in comparison.

pure oil

soluble bath oil

dispersing bath oil

Fig. 6: Microscopic view of mousse.

gas bubbles

cream la-mellas

Skin Care


should not dry your skin too vigorously, other-wise the beneficial effect is lost.

Skin Care that ‘Breathes’

The skin is said to ‘breathe’ because it discharg-es vapour to the environment. If this process is hindered, an ‘occlusion’ occurs, which leads to over-heating. A complete occlusion, for in-stance, with a thick smear of petroleum jelly, causes a disruption in the renewal and devel-opment of the cells in the epidermis, as well as their metabolism. This damages the horny lay-er, that is, the skin barrier. When cosmetics are applied, the occlusive effect is only temporary, the length of which depends upon:

• the type of base used (pure oils, pure fats, wa-ter-in-oil emulsions, oil-in-water emulsions)

• the amount and type of lipids used• additives, such as dispersants or emulsifiers• the amount of product applied and whether

is is rubbed in

A partial occlusion can be effective when using skin care products, as this increases the mois-ture level of the skin.

Skin care which allows your skin to breathe com-bines effective care and enables water vapour to escape at the same time. A measurement of

Target parameter Test method

barrier function transepidermal water loss (TEWL)

hydration of the skin

corneometry

lipid content sebumetry

cutaneous pH value

pH-metry

skin elasticity cutometry

epidermal structure

profilometry

cutaneous structure

sonography, confocal la-ser scanning microscopy, confocal raman microscopy

Table 2: Usual methods for proving the effective-ness of skin care products.

the TEWL under controlled conditions is the only way to conclusively assess how occlusive a prod-uct really is. A test such as this will show exact-ly how much water vapour is lost shortly after applying a product.

Additional Ingredients in Skin Care Products

To enhance the effect of skin care prod-ucts for people with diabetes, certain sub-stances are added in the manufacturing pro-cess to absorb water (humectants) or to en-rich the skin’s natural lipid film (emollients). In addition, certain ingredients are added to creams for the feet to soften hard skin and calluses and to prevent invasions of bacteria. The most significant of these types of prod-ucts is urea. This substance increases the skin’s ability to hold moisture and, in high-er concentrations (over 10%), softens and reduces the hard skin layers. Thus, urea has a keratoplastic and keratolytic effect. Other ingredients used in cosmetic prod-ucts for dry skin are glycerine, vitamin E, panthenol, lactic acid, sodium lactate, bet-ulinic acid, N-palmitoylethanolamine, hy-aluronic acid and St John’s wort extract.

Oily baths used after showering

Oily baths are part of the skin care regimen, and should be used only af-ter cleaning the skin. Therefore, bath oils may also be applied to the skin af-ter showering and then briefly rinsed off. Afterwards the skin should not be dried too vigorously so that the oil does not rub off.

Skin Care


The dry skin of a diabetic requires special attention. Suitable products need to impart sufficient fat and moisture to the skin. The various ga-lenic forms of skin care products sig-nificantly influence their effective-ness and ease of application. Their recipes on paper only give a hint as to how they differ from each other. Conclusive data can only be collected in controlled studies.

Lipids of various chemical classes such as triglyc-erides (vegetable or semisynthetic oils), solid and liquid wax esters (cetyl palmitate or isopropyl palmitate), fatty alcohols, fatty acids such as stearic acid, sterols (lanolin) and phytosterols, and partial glycerides (glycerol monostearate) are just some of the countless synthetic and nat-ural products used in the making of emollients.

Ingredients that are used as antiseptics are oc-tenidine hydrochloride, polyhexanide and mi-crosilver.

Skin Care


Effectiveness and Tolerability of Skin Care Products

Just the recipe of a skin care product cannot determine the product’s effectiveness and tol-erability from the outset. All this – the prod-uct’s moisture and fat-containing ability, as well as its barrier effect – has to be tested in-vivo under controlled conditions. The basic method used here is to compare somebody with treated skin to a control person with un-treated dry skin (intraindividual comparison). The objective assessment is usually done by biophysical measurement along with spectro-scopic and microscopic examination (Tab. 2). Not only the effectiveness of the product, but also its tolerability (irritation potential, sensitization potential, comedogenic effect) needs to be evaluated in-vivo on test per-sons or in-vitro under laboratory conditions. Detailed guidelines on these themes can be found, for example, in the Society of Dermo-pharmacy’s ‘Dermocosmetics for Cleansing and Caring for Dry Skin’ (www.gd-online.de).

Author: Prof. Dr. Rolf DanielsEberhard-Karls-Universität TübingenAuf der Morgenstelle 8, 72076 Tübingen


Useful Facts on Cosmetic Ingredients

In the daily work of dermatologists and podia-trists the question arises again and again as to what’s in cosmetic and skin care products. “What is the most suitable product for my skin type?” “Which creams do you recommend?” or “What do you think of such and such a product?”

Reference for the clinic

We would like to present an overview of the most important ingredients of skin care products and their effects. This may be used as a quick ref-erence to be of assistance in the clinic.

In the European Union, all contents of skin care products must be declared on the packaging, so that all ingredients of the product can be identified.

Principally, it is important to know that the words “dermatologically tested” is not protected. This means, there exists no standardized criteria of quality to control who carries out the dermato-logical tests or how they are done. The words “suitable for diabetics” doesn’t necessarily guar-antee that product is indeed suitable for diabet-ics. This is why it is important to pay attention to the safety and benefit studies – something that can always be depended upon for pharmaceu-tical products.

Ingredients

Ingredients


Alcohol

Synonyms: ethyl alcohol, ethanolOrigin/Production: Alcohols are organic hydro-carbon compounds whose hydrogen atoms are displaced by hydroxyl groups. They are catego-rized into one-, two-, three- or polyhydric al-cohols, depending on the number of hydroxyl groups, and primary, secondary and tertiary alco-hols, depending on the connecting area, where the hydroxyl group binds to the hydrocarbon. The most important alcohols are, among oth-ers, ethanol, glycerine, isopropanol, propylene glycol, and sorbitol.Properties/Applications: Alcohol is used in cos-metics as a disinfectant, preservative, fragrance, and solvent. If used in high concentrations, it can have a drying effect on the skin.

AllantoinSynonym: AllantoinOrigin/Production: Allantoin is an endproduct of the oxidation of uric acid by purine catabo-lism. It is present in most mammals as well as in plants (wheat germ, comfrey root, the bark of the horse chestnut tree). Properties/Applications: Allantoin, in the form of clear, shiny leaflets or as a crystal powder, is used in the manufacturing of skin care products (clarifying lotions, moisturizers, sun care prod-ucts, lip balms) as well as in pharmaceutical prod-ucts used for dry skin. It is fragrance free, taste-less, fat-soluble, and anti-irritant. It is soothing, anti-inflammatory, promotes cell proliferation, keratolytic, smoothes rough skin, and increases the moisture content of the epidermis.

Aloe Barbadensis ExtractSynonyms: aloe veraOrigin/Production: Aloe vera is the name given to a species of cactus from the lily family that thrives in the desert (over 200 types), with thick fleshy leaves. Only the gel-like flesh of the leaves

is used in cosmetic products. It is pressed, and the resulting slime extracted, filtered, and pas-teurized. The gel is not only rich in minerals, but also contains numerous other substances such as enzymes, amino acids, sterols, vitamins, and mucopolysaccharides.Properties/Applications: Aloe vera has healing properties, imparts moisture, reduces pain, re-duces inflammation, and cools. It is even said to protect against UV rays to a certain extent.

Arnica Montana ExtractSynonyms: leopard’s bane, wolf’s bane, moun-tain tobacco, mountain arnica, arnica , arnica fulgens, arnica sororia.Origin/Production: Arnica is a medicinal plant belonging to the daisy family. The petals contain a highly poisonous essential oil. It also produc-es bitters and tannins as well as secondary plant products (carotinoids, flavonoids). The essential oil of the plant is extracted from the flowers and the roots via steam distillation.Properties/Applications: The essential oil is used as fragrance in perfumes, or as a tincture in creams for the skin and feet. The substance is considered to be an irritant.*

Benzoic Acid/Sodium BenzoateSynonyms: benzenecarboxylic acid, benzene-formic acidOrigin/Production: Benzoic acid is found in ber-ries, and in an Asian gum resin, but is now most-ly manufactured synthetically.Properties/Applications: The weak acid is used, due to its antiseptic and antimycotic qualities, as a food preservative.

Biotin

Synonyms: vitamin B7, vitamin HOrigin/Production: Biotin is a natural and com-monly occuring water-soluble vitamin. In hu-

Ingredients


mans, it is responsible for, among other things, the maintenance of healthy skin, hair and nails. Clinical manifestations of biotin deficiency are evident in the form of skin eruptions, dry skin, hair loss, brittle nails, and irritability. Properties/Applications: Due to its nurturing and antiseborrheic qualities, it is used in the care of hair and nails.

Butyrospermum Parkii Butter

Synonyms: shea tree butter, karité butterOrigin/Production: The oil is extracted from the kernels of the shea fruit by cold pressing.Properties/Applications: Due to its caring, smooth-ing and moisturizing qualities, shea butter is used in cosmetics as an emollient. It is also used as a skin care product, especially for sun damage.

Cera Alba

Synonyms: beeswaxOrigin/Production: Beeswax is excreted by bees to build honey cone.Properties/Applications: Beeswax is produced as an ingredient in skin care products in the form of Cera flava (yellow wax) and Cera alba (white wax). It cares and protects sensitive skin. It is mainly used in natural cosmetics.

Cetearyl AlcoholSynonyms: cetostearyl alcoholOrigin/Production: Cetearyl alcohol is a mixture of cetyl and stearyl alcohols.Properties/Applications: Cetearyl alcohol imparts a silky, emollient feel to the skin. It is used as an emulsion, and as an opacifying and viscosity-in-creasing agent.

Citric Acid

Synonyms: hydrogen citrateOrigin/Production: This organic acid is the most commonly occuring in the plant world,

and plays a role in the metabolism of all liv-ing things. It is extracted biotechnologically from the juice of citrus fruits. Once extracted, it forms clear and odourless crystals, or a sour crystalline powder.Properties/Applications: Citric acid has bleach-ing properties. It acts as an astringent, and pos-itively influences the rate of cell regeneration. Thus, it is used as a buffer compound. It is also used in astringents and, due to its ability to che-late metals, in soaps. It may contain residues of allergenic material.*

Dimethicone

Synonyms: polydimethylsiloxane (PDMS), sili-cone oilOrigin/Production: This silicone oil is a synthetic mix of fully methylated, linial siloxane polymers.Properties/Applications: It is anti-allergenic and makes the skin feel smooth. It is used as an emol-lient and anti-foaming agent. Not being very biodegradable, its use is environmentally ques-tionable. Natural alternatives to this product are almond oil, avocado oil, and fats.*

GlycerinSynonyms: glycerol, glycerineOrigin/Production: Glycerin is the simplest tri-valent alcohol present in, depending on its fat-ty acid compound, vegetable and animal fat. It can be synthetically produced or extracted from plants. It is also a by-product in the mak-ing of soap.Properties/Applications: Due to its hygroscopic properties, it is used as a humectant in moistur-izers. In high concentrations of over 30%, how-ever, it dries and irritates the skin.

Hyaluronic Acid

Synonyms: hyaluronan, hyaluronateOrigin/Production: Hyaluronic acid is a highly viscous, naturally occuring mucopolysaccharide

Ingredients


found in the connective and lubricating tissues of the body. It is made up of glucuron acid and ace-tylchondrosamine or acetylglucosamine. Along with collagen, it makes up a significant part of the synovial fluid, that mobilizes the water-sol-uble substances between the cells. As one gets older, the amount of naturally occuring hyal-uronic acid lessens, thus the skin loses its ability to hold moisture and its elasticity. Properties/Applications: Due to its ability to hold moisture, hyaluronic acid can transport water to matrix of the connective tissue. It al-so builds a film, permeable to air, protecting the stratum corneum from drying out. Hyal-uronic acid is, therefore, used as an ingredient in moisturizers.

Lanolin

Synonyms: wool wax, lanoline, adeps lanae, ce-ra lanaeOrigin/Production: Lanolin is produced in the se-baceous glands in the skin of the sheep, and ex-tracted from its wool after being shorn. It con-tains a mixture of wool wax (65%), water (20%), and mineral or vegetable oil such as paraffin (15%).Properties/Applications: Due to its softening and moisturizing properties, this substance is widely used in pharmaceutical and cosmetic products, for instance, as a base for creams and ointments. In addition, it is used as an antistatic, an emol-lient, an emulsifier, a skin care product, and a surfactant. As lanolin can contain residues of pesticides, products containing lanolin used to have to state “contains lanolin” to warn con-sumers against a possible allergic reaction. Why this warning is no longer obligatory is unclear.*

Myroxylon Pereirae Resin

Synonyms: Peru balsam, balsamum peruvianumOrigin/Production: Peru balsam is a substance in plants extracted by smoking the bark of trees.Properties/Applications: Peru balsam is used as a

fragrance or active ingredient in cosmetic prod-ucts. It contains, however, allergic potential.*

Oenothera Biennis OilSynonyms: primrose oil, evening primrose oilOrigin/Production: The oil of the seeds of the primrose flower contains unsaturated fatty acids (linoleic, linolenic, oleic acids). The primrose grows in north America, Europe, Turkey, New Zealand and Australia. Properties/Applications: It positively affects the epidermal barrier function in dermatitis and is used to moisturize dry skin. Primrose oil is sooth-ing to the skin.

Olea Europaea Oil

Synonyms: olive oilOrigin/Production: Olive oil, a yellowish-green oil, is obtained from the little fruits of the olive tree by cold pressing. The olive tree is native to the mediterranean regions. Olive oils is a rich source of unsaturated fatty acids (oleic, palmit-ic and linoleic acids), vitamins A and E, as well as traces of minerals.Properties/Applications: Olive oil is smoothing to the skin. It acts as a lubricant and moisturizer.

Panthenol

Synonyms: D-panthenol, provitamin B5Origin/Production: Panthenol is the precursor to pantothenic acid, the substance that is trans-formed enzymatically into the vitamin D-pan-tothenic acid (vitamin B5). It is present in all liv-ing cells. Properties/Applications: Panthenol has soothing and anti-inflammatory properties. It smoothes the skin, imparts moisture, and supports the wound-healing process.

Ingredients


Parabens

Origin/Production: Parabens are a group of pa-ra-hydroxybenzoic acid esters such as methyl, ethyl, butyl, and propyl parabens.Properties/Applications: Parabens are used as preservatives, as they hinder the development of microorganisms (especially yeasts and moulds) in the manufacturing of cosmetics.

Persea Gratissima Oil

Synonyms: avocado oil, alligator pear oilOrigin/Production: The edible fat of the dark green to brownish red avocado pear, originat-ing in middle and south America. The oil is ex-tracted from the flesh of the fruit through cold compression. The fruit contains high levels of an-tioxidants (vitamins A and E), vitamin D, B6, po-tassium, magnesium, phytosterols and lecithin. It is rich in unsaturated fats.Properties/Applications: Avocado oil is used in cosmetics as an emollient. Due to its replenish-ing, healing, softening and hydrating effects, av-ocado oil is used in products for dry, scaly and mature skin. Due to its high content of antioxi-dants, it takes longer to go rancid.

Propylene GlycolSynonyms: alpha-propylene glycol, methyleth-ylene glycolOrigin/Production: A clear, odourless liquid with a sweet taste, and is synthetically produced. It belongs to the class of alcohols that are derived from the alkanes.Properties/Applications: Propylene glycol is hy-groscopic and is, therefore, used as a humec-tant in moisturizers and as a skin conditioner. It is also used as a solvent and viscosity controller.

Prunus Amygdalus Dulcis Oil

Synonyms: almond oilOrigin/Production: The oil is extracted by cold

compression from the kernels of the nuts of the sweet almond tree, native to Asia, north Afri-ca, Israel, California and the mediterranean re-gions. The light yellow oil is almost odourless. It contains oleic and linoleic acids, but quickly becomes rancid.Properties/Applications: Almond oil replenishes the skin’s moisture and helps it in healing. It is used as an emollient and as a skin care product.

Retinol

Synonyms: vitamin AOrigin/Production: A fat-soluble, essential vita-min. The provitamin, betacarotine, is converted to vitamin A in the human body. Products con-taining retinol must be protected with antiox-idants and light.Properties/Applications: Retinol replenishes the skin’s moisture, and raises the mitosis activity of the cells and promotes cell proliferation.

Silver

Synonyms: microsilverOrigin/Production: Elemental silver, as well as its alloys, are used in products. The active sub-stances, however, are its ions. Properties/Applications: Silver is used as an an-timicrobial substance in skin care products.

Saccharide Isomerate

Synonyms: PentavitinTM

Origin/Production: Saccharide isomerate is an acqueous solution of carbohydrates present in the epidermis. It is extracted from natural sugar.Properties/Applications: It improves the mois-ture-holding ability of the Stratum corneum. It binds with keratin so that the moisturizing par-ticles on the surface of the skin cannot easily be washed away, neither with soaps nor with wa-ter. Thus, its moisturizing benefits remain over a long period of time. For this reason, it is known as the ‘moisture magnet’.

Ingredients


Simmondsia Chinensis Oil

Synonyms: jojoba oilOrigin/Production: Jojoba oil is extracted using cold compression from the seeds of the Simmond-sia chinensis plant, a shrub native to the coastal desert areas of America. It is a light yellow, liq-uidy wax containing erucic, oleic and gado leic acids. It resembles the fat mix in human skin.Properties/Applications: Jojoba oil is easily ab-sorbed into the skin, hence it is used in prod-ucts for all skin types, but mainly for dry skin. Jojoba oil is used as an emollient and feels very smooth on the skin. Apart from this, it has a very long shelf-life.

Sodium Chloride

Synonyms: saltOrigin/Production: Salt is obtained from salt re-serves, brine, salt lakes, and sea water, by min-ing rock salt. It is composed of chloride and so-dium ions.Properties/Applications: Sodium Chloride is used to control viscosity and as a swelling agent.

Sorbitol

Synonyms: glucitol, sugar alcoholOrigin/Production: Sorbitol is a white, crystal-line, weakly hygroscopic, odourless, sweet-tast-ing powder present in many fruits (berries, cher-ries, apples, plums). It can also be manufactured from glucose with the help of certain enzymes.Properties/Applications: Sorbitol is used as a hu-mectant and thickener in moisturizers.

Stearic Acid

Synonyms: octadecanoic acidOrigin/Production: Stearic acid is saturated fatty acid found in plant and animal fats. It is white, solid, waxy and odourless.Properties/Applications: In cosmetics, stearic acid

is used as a cleanser and moisturizer, as emulsi-fier and stabilizer.

Tocopherol/Tocopheryl AcetateSynonyms: vitamin E, vitamin E acetateOrigin/Production: Vitamin E consists of all the tocopherol and tocotrienol derivatives, whose bi-ological activity qualitatively belongs to the RRR-alpha-tocopheral (or ddd-gamma-tocopherol) stereoisomers. Vegetable oils, such as wheatgerm oil and sunflower oil, as well as grains, seeds and nuts, contain considerable amounts of fat soluble vitamins. Vitamin E acetate is a more stable form of tocopherol. Tocopherols are obtained by chem-ical manufacturing, or through natural means. Properties/Applications: Tocopherol moistur izes the skin. Tocopherols are used in combination with antioxidants and free radical scavengers.

UreaSynonyms: carbamideOrigin/Production: Urea is a naturally occuring, non-allergenic substance involved in the meta-bolism of amino acids. Nowadays, urea is syn-thetically manufactured.Properties/Applications: Urea is a natural water retainer. It belongs to one of the natural mois-turizing factors (NMF) of the keratic outer skin layer (Stratum corneum), enhancing its moisture-containing ability. Depending on the concentra-tion, urea not only rehydrates the skin, it can al-so be used as a debriding agent, an anti-irritant, or as an antiseptic.

Vitis Vinifera Seed Oil

Synonyms: grape seed oilOrigin/Production: Grape seed oil is extracted from the pips of grapes that grow in the clima-tically temperate subtropical regions. Above all, it contains linoleic and oleic acids, as well as vi-tamin E.

Ingredients


Properties/Applications: Grape seed oil nourishes the skin, aids in skin repair, and is also used as an emollient and antioxidant in skin care products.

Zinc Oxide

Synonyms: zinc white, calamineOrigin/Production: A white mineral powder.Properties/Applications: Zinc oxide is used in top-ical healing products. It has astringent and dry-ing effects. It is also used as a swelling agent as well as a UV-filter.

* As determined, among other sources, by the ÖKO-TEST-Kosmetik-Liste.


▶ The Diabetic Foot Syndrome

The clinical guidelines entitled ‘The Di-abetic Foot Syndrome’ appeared at the end of 2008. In this publication, the au-thors, Dr. Martin Lederle, Dr. Joachim Kersken and Prof. Maximilian Spraul, examine thoroughly the Type 2 Diabe-tes National Guidelines. In just under 30 pages, the reader can find everything that is crucial in the treatment of the diabetic foot.

If interested, please contact:

neubourg skin careMergenthalerstr. 4048268 GrevenTelefon: 0 25 71 / 57 40 - 0Telefax: 0 25 71 / 57 40 - 1 00


Addresses

Associations and Institutions

ABDA – Bundesvereinigung Deutscher Apothekerverbände Jägerstr. 49/50 10117 Berlin Tel.: 0 30 / 4 00 04 - 0 Fax: 0 30 / 4 00 04 - 5 98 E-Mail: [email protected]: www.abda.de

Berufsverband Deutscher Diabetologen e.V. (BDD)Waldstraße 6 A14548 Schwielowsee-CaputhTel.: 0 33 / 2 09 22 99 - 70Fax: 0 33 / 2 09 22 99 - 75E-Mail: [email protected]: www.bvdk-ev.de

Bund Diabetischer Kinder u. Jugendlicher e.V. (BDKJ)Hahnbrunner Str. 4667659 KaiserslauternTel.: 06 31 / 7 64 88Fax: 06 31 / 9 72 22E-Mail: [email protected]

Bundesverband Klinischer Diabetes- Einrichtungen e.V.BundesgeschäftsstelleDiabeteszentrum Bad LauterbergKirchberg 2137431 Bad LauterbergTel.: 0 55 24 / 81 - 2 12Fax: 0 55 24 / 81 - 7 77E-Mail: [email protected]: www.bvkd.de

Useful Addresses in Germany

Bundesverband Niedergelassener Diabetologen e.V. (BVND)Geschäftsstelle c/o med info GmbH Hainenbachstr. 25 89522 HeidenheimTel.: 0 73 21 / 94 99 19Fax: 0 73 21 / 94 98 19E-Mail: [email protected]: www.bvnd.de

Deutsche Diabetes-Gesellschaft (DDG)Geschäftsstelle der DDGReinhardtstraße 3110117 BerlinTel.: 030 / 311 6937 - 0Fax: 030 / 311 693720E-Mail: [email protected]: www.ddg.info

AG Fuß der Deutschen Diabetes-GesellschaftBettin BaumannPostfach 118267321 SpeyerE-Mail: [email protected]: www.ag-fuss-ddg.de

Deutsche Diabetes-Stiftung (DDS)Staffelseestr. 6 81477 München Tel.: 0 89 / 57 95 79 - 0 Fax: 0 89 / 57 95 79 - 19 E-Mail: [email protected]: www.diabetesstiftung.de


Addresses

diabetesDEGeschäftsstelleReinhardtstraße 3110117 BerlinTel: 0 30 / 20 16 77 0Fax: 0 30 / 20 16 77 20E-Mail: [email protected]: www.diabetesde.orgStiftung „Der herzkranke Diabetiker“ in der DDS Georgstraße 11 32545 Bad Oeynhausen Fax: 0 57 31 / 97 21 22 E-Mail: [email protected]: www.stiftung-dhd.de

Verband der Diabetes-Beratungs- und Schulungsberufe in Deutschland e.V. (VDBD)Am Eisenwald 16 66386 St. IngbertTel.: 0 68 94 / 5 90 83 13Fax: 0 68 94 / 5 90 83 14E-Mail: [email protected]: www.vdbd.de

Verband Deutscher Podologen (VDP)Obere Wässere 3-7D-72764 ReutlingenTel.: +49 7121 / 33 09 42Fax: +49 7121 / 31 00 89E-Mail: [email protected]

Zentralverband der Podologen und Fuss-pfleger Deutschlands e.V. (ZFD)Schaumburgstraße 14-1645657 RecklinghausenTel.: 0 23 61 / 18 59 60Fax: 0 23 61 / 18 59 61E-Mail: [email protected]: www.zfd.de

Bundesverband und Landesverbände des Deutschen Diabetiker Bundes

Deutscher Diabetiker Bund e. V. (DDB)BundesverbandGoethestr. 2734119 KasselTel.: 0 5 61 / 70 34 77 0Fax: 0 5 61 / 70 34 77 1E-Mail: [email protected]: www.diabetikerbund.de

Landesverbände

LV Baden-Württemberg e. V.Elke BrückelKriegsstr. 4976133 KarlsruheTel.: 07 21 / 3 54 31 98Fax: 07 21 / 3 54 31 [email protected]

LV Bayern e. V.Bernd FranzDiabetikerbund Bayern e. V.Ludwigstr. 67 90402 NürnbergTel.: 0911 / 22 77 15Fax: 0911 / 23 49 [email protected]

LV BerlinReiner TippelSchillingstr. 1210179 BerlinTel.: 0 30 / 2 78 67 37Fax: 0 30 / 2 75 91 [email protected]


Addresses

LV Brandenburg e. V.Eberhard NowotnikSchopenhauerstr. 3714467 PotsdamTel.: 03 31 / 9 51 05 88Fax: 03 31 / 9 51 05 90info@diabetikerbund-brandenburg.dewww.diabetikerbund-brandenburg.de

LV Bremen e.V. Hartmut SteinbeckAm Wall 10228195 BremenTel.: 04 21 / 6 16 43 23Fax: 04 21 / 6 16 86 [email protected]

LV Hamburg e.V. Manfred Mohnke Steinstraße 1520095 Hamburg Tel.: 0 40 / 20 00 43 80Fax: 0 40 / 20 00 43 88 [email protected]

LV Hessen e.V. Prof. Dr. Hermann von Lilienfeld-ToalFriedrich-Ebert-Str. 534613 Schwalmstadt-TreysaTel.: 0 66 91 / 2 49 57Fax: 0 66 91 / 2 49 [email protected]

LV Mecklenburg-Vorpommern LV in Gründung. RA Dietrich Monstadt Lübecker Str. 5 19053 Schwerin

LV Niedersachsen e.V. Almut SuchowerskyjAm Nottbohm 46a 31141 HildesheimTel.: 0 51 21 / 87 61 73Fax: 0 51 21 / 87 61 [email protected]

LV Nordrhein-Westfalen e.V. Martin HadderJohanniterstr. 4547053 DuisburgTel.: 02 03 / 6 08 44 - 0Fax: 02 03 / 6 08 44 - [email protected]

LV Rheinland-Pfalz e.V. Alois MichelTheodor-Fliedner-Str. 2555218 IngelheimTel: 0 61 32 / 8 59 77Fax: 0 61 32 / 71 21 [email protected]

LV Saarland e.V. Karl ZangWolfskaulstr. 4366292 RiegelsbergTel.: 0 68 06 / 95 35 71 Fax: 0 68 06 / 95 35 [email protected]

LV Sachsen e.V. Rosmarie WalligStriesener Str. 3901307 DresdenTel.: 03 51 / 4 52 66 52Fax: 03 51 / 4 52 66 [email protected]


Addresses

LV Sachsen-Anhalt e.V. Reinhold MeintzingerNeuer Weg 22/2306484 QuedlinburgTel. und Fax: 03946/528483 [email protected]

LV Schleswig-Holstein e.V. Martin LangeAuguste-Viktoria-Str. 1624103 KielTel.: 04 31 / 18 00 09Fax: 04 31 / 12 20 [email protected]

LV Thüringen e.V. Edith ClaußenWaldenstraße 13a99084 ErfurtTel./Fax: 03 61 / 7 31 48 19 [email protected]

Websites of Self-Help Groups

http://www.selbsthilfenetz.de/content/index_ger.htmlhttp://www.dag-selbsthilfegruppen.de/site/http://www.koskon.de/

Useful international Adresses

EASDRheindorfer Weg 340591 DüsseldorfGermanyTel.: +49/211-758 469 0Tel.: +49/211-758 469 [email protected] Director: Dr. Viktor Jörgens

IDFInternational Diabetes FederationChaussée de la Hulpe 166B-1170 Brussels, BelgiumTel.: +32/2-5 38 55 11Tel.: +32/2-5 38 51 [email protected]

Documents

Clinical Guidelines Diabetes and the Skin · Perleche. DYM is one of the most commonly accepted systems of categorization used in medical mycology for the clinical diagnosis and treatment