Diabetic Skin Changes Can Benefit from Moisturizer and Cleanser Use: A Review

December 2019 | Volume 18 | Issue 12 | Original Article | 1211 | Copyright © December 2019


Robert S. Kirsner MD PhD,a Gil Yosipovitch MD FAAD,b Shasa Hu MD FAAD,cAnneke Andriessen PhD,d Jason R. Hanft DPM FACFAS,e Paul J. Kim DMP MS,fLawrence Lavery DPM MPH,g Luigi Meneghini MD MBA,h Lee C. Ruotsi MD ABWMS CWS-P UHMi

aUniversity of Miami Hospital Wound Center and Chief of Dermatology, University of Miami Hospital, Miami, FL;
Harvey Blank Chair in Dermatology, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, Miami, FL
bMiami Itch Center, Miami, FL; Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, Miami, FL
cDr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL;
Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Sylvester Comprehensive Cancer Center, Miami, FL
dAndriessen Consultants, Malden, Netherlands, and Radboud University Nijmegen Medical Centre, Netherlands
ePodiatric Surgery Specialist, Foot & Ankle Institute of South Florida, South Miami, FL; South Miami Hospital, South Miami, FL
fMedStar Plastic & Reconstructive Surgery, MedStar Health Inc., Washington, DC;
Georgetown University School of Medicine, Washington, DC
gUT Southwestern’s Comprehensive Wound Care Center, Dallas, TX; Plastic Surgery, Orthopaedic Surgery,
and Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, TX
hGlobal Diabetes Program, Parkland Health and Hospital System, Dallas, TX; Internal Medicine,
University of Texas Southwestern Medical Center, Division of Endocrinology, Dallas, TX
iCatholic Health Advanced Wound Healing Centers, Buffalo, NY

der-utilized. Skin care is frequently lacking or overlooked as part of patients’ DM skin treatment.3 

To address these unmet needs, a review paper was developed to explore DM skin changes and possible benefits of appropriate cleanser and moisturizer use in DM skin treatment.

METHODS

An expert panel of physicians involved in the care of patients with DM convened in Miami, FL, in March 2019, to deliberate about diabetic skin changes and the impact of cleanser and moisturizer use on skin health. For this purpose, selected information from literature searches coupled with expert opinions and experience of the panel were used. The literature review was conducted prior to the meeting; the results were presented and discussed during the meeting. The selected literature was deemed clinically relevant to DM skin changes and challenges in treating diabetic skin. Skin conditions that differ from DM skin changes, or those that would not necessarily benefit from cleanser and moisturizer use, are outside the scope of this review.

Diabetes Mellitus and Related Skin Changes
DM-related skin changes are a common complication seen in both type 1 and type 2 DM.2 Dermatologic conditions linked with DM vary in severity and while usually benign can in certain circumstances lead to major complications, including amputations.4,5 Cutaneous manifestations in DM may be classified into four categories: 1) Skin associated with DM (from strongest to weakest association include necrobiosis lipoidica, diabetic dermopathy, diabetic bullae, yellow skin, eruptive xanthomas, perforating disorders, acanthosis nigricans, oral leucoplakia, lichen planus); 2) Infections (bacterial, fungal); 3) Cutaneous manifestations of diabetic complications (microangiopathy, macroangiopathy, neuropathy); and 4) Skin reactions to diabetes treatment (ie, sulphonylurea rash or insulin lipohypertrophy).2 Additionally, hyperglycemia may lead to skin changes (Table 1), the mechanism of action is unclear and other factors are likely involved.2,6

In patients with DM, functional properties of the stratum cor- neum (SC) may be altered, impacting skin barrier function.4 A defective skin barrier predisposes the skin to water loss and to invasion by pathogens, which in turn may lead to dryness, hyperkeratosis and redness from inflammation.7 The status of the permeability and antimicrobial barrier of the skin in DM remains unknown.2 In-vivo impairment of the skin barrier was observed in type 2 DM mice models, which results from impairment of skin barrier homeostasis and decreases in epidermal prolifera- tion and epidermal lipid synthesis.8

In vivo and in vitro, pre-clinical studies show that, diabetes alters epidermis histology and suppresses proliferation of keratinocytes.9 Impaired keratinocyte homeostasis and epidermal barrier function, results in higher risk of chronic wounds and infection.10,11,13-15