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

Ichthyosiform Skin Changes
These ichthyosiform skin changes present as large bilateral areas of dryness and scaling, and may be described as “fish scale” skin (Figure 4).21,22 Development of ichthyosiform skin changes is related to production of advanced glycosylation end products and to microangiopathic changes.21,22 Treatment of these skin changes is limited; however, topical moisturizers containing keratolytic agents may be beneficial.21,22

Xerosis Due to DM
Xerosis presents as abnormally dry skin that may also show scaling or fissures, and appears most commonly on the feet in patients with DM (Figure 5).3-5,18-20 Dry skin conditions result from an abnormal, persistent cohesion between corneocytes, with secondary thickening of the SC, impaired moisturization of the uppermost SC layers, increased transit time of corneocytes in the SC, and altered skin barrier function.12,23,24 The decreased sebaceous gland activity in patients with DM further contributes to a reduced hydration state of the SC.The physical characteris- tic of the SC depends on its moisture content and water holding capacity.12

Patients with dry skin may have a feeling of skin tightness, especially after showering, bathing or swimming.3 The skin may feel shrunken or dehydrated and looks rough rather than smooth.3 Itching and pain may be intense and there may be slight to severe scaling or peeling, fine lines, cracks and/or fissures, erythema, and inflammation.3-5,18-20 Deep fissures that may bleed are frequently present in the more severe cases and pose a risk for infection (Figure 6).3-5,18-20 Skin barrier dysfunction may be compounded by excessive keratin formation resulting in hyperkeratosis.20 Xerosis and hyperkeratosis can be triggered by shoes constructed of materials, that do not allow for sufficient moisture evaporation, by improperly fitting shoes, socks and stockings, by excessive perspiration, and by heating or air conditioning that reduces humidity and dries the skin.20 Other factors leading to cracked skin on heels are prolonged standing, especially on hard floors, and being overweight, which increases the pressure on the normal fat pad under the heel.20 If the skin is not supple and flexible, the pressure to crack is high.This may be the case in open backs on shoes, which allow the fat pad under the heel to expand sideways, thereby increasing the pres- sure and causing the skin to crack.20

In dry skin, the risk for infection is enhanced.The protective acid mantle is less functional while the warm moist environment in poor footwear may predispose to the development of skin infection.3-5,18-20

Xerosis in DM is often associated with pruritus, mostly localized, such as on the scalp, ankles, feet, trunk, or genitalia. Pruritus is more likely in those patients with DM who have dry skin and/ or neuropathy.15,25 Involvement of the genitalia or intertriginous areas may occur in those who have an infection (eg, candidia- sis).15,25

Keratosis Pilaris
Keratosis pilaris presents on the extensor surfaces of the upper arms (Figure 7) and less frequently on the thighs, face and but- tocks.21 Compared to the general population, keratosis pilaris occurs more frequently and with more extensive involvement in those patients with DM. Keratosis pilaris can be treated with various topical therapies, including salicylic acid-containing moisturizers, combined with gentle exfoliation.21

Skin Care for Diabetic Skin Changes
Adherence to treatment is a considerable challenge in people with DM,1-5 making education essential, especially about the need to keep the skin clean and with regard to what cleansers to use.3 Using cleansers with a high pH (9.0–10.0) increases skin pH, thereby causing irritation and leading to lower lipid production. However, conclusive evidence is lacking that shows lowered skin pH, using near-physiologic skin surface pH (4.0–6.0) products, improves diabetic skin.1-5