Diabetes Mellitus
Diabetes mellitus (DM) is a syndrome characterised by high blood sugar caused by a partial or complete lack of insulin. The exact cause of the disease is not known. Environmental factors and genetic predisposition are emphasised.
The prevalence of DM in the population is around 10%. Broadly, there are two classes: type 1 and type 2.
TYPE 1 DM:
By the time high blood sugar appears, 90% of the pancreas in patients with this type of diabetes must already have been destroyed.
TYPE 2 DM:
It is mostly seen in patients who are obese and have developed insulin resistance. The disease appears when a defect of the insulin-producing beta cells of the pancreas is added to these two factors.
TYPE 1 / TYPE 2
Age at onset: Under 40 / Over 50
Duration of symptoms: Within weeks / Within months
Weight: Normal / Obese
Insulin treatment: Essential / Not necessary
Furuncle (Boil):
An acute, localised, deep folliculitis and perifolliculitis of the dermis and subcutaneous tissue that ends in suppuration. It is most often located in areas subject to friction and sweating. Obesity, diabetes, immunosuppression and chronic itchy diseases play a predisposing role.
It starts as a firm, tender, painful, red and warm nodule in and around a hair follicle. There is a necrotic plug on top of the lesion. The nodule grows rapidly and becomes fluctuant within a few days. The softened lesion opens and bloody pus is discharged together with the necrotic plug. After it opens, the pain decreases markedly and the swelling and redness begin to subside. The ulcer at the opening heals within a few days or weeks, leaving a scar.
If new foci develop while a furuncle is healing, the term furunculosis is used. In this situation, it should be questioned whether the treatment previously given was appropriate and adequate. In a person who develops furunculosis despite appropriate treatment, the presence of predisposing factors should be investigated.
Furuncles located in the armpit and groin should be distinguished from hidradenitis suppurativa.
Diabetic dermopathy: one of the most common skin signs in patients with diabetes – though not as dangerous or serious as the others – is a disorder called diabetic dermopathy. It is a disorder of the skin seen especially on the lower legs, over and in front of the shin bone. Its cause is unknown. Its mechanism is not very clear, but it is a characteristic sign. First red and brown bumps appear, then scaling is seen on them, and later, in a way that is again not fully understood, they heal leaving a small depression. They are sometimes linear and sometimes dot-like, and none of these signs easily attracts attention; they can be overlooked. However, they can be noticed through careful observation by an attentive doctor and an attentive patient. Noticing them may lead to the discovery of previously undiagnosed diabetes. First, because they occur in diabetes of rather long duration, the diabetes must have been neglected for quite a while. Second, their presence may be a sign that other diabetes-related organ involvement and disorders have also begun. If such a finding is present during a patient's follow-up, the other organs must also be checked, and the kidneys and eyes in particular will need to be assessed.
Acanthosis Nigricans
Acanthosis nigricans is an uncommon condition, for which there is no cure, in which thickened, dark patches of skin appear in the groin, armpits, neck and other skin folds. Although acanthosis nigricans (AN) is associated with multiple endocrinopathies, there are not many cases in the literature (the available data) in which acanthosis nigricans has been seen together with hypothyroidism.
Acanthosis nigricans can appear in young people as a genetic disorder, or as a result of an endocrine disorder such as Cushing's syndrome, in patients with insulin resistance, in acromegaly, in people with Addison's disease, in Prader-Willi syndrome, in people with polycystic ovary syndrome and in patients with hypothyroidism. It can also appear in people with cancer of the lung and other organs. Acanthosis nigricans can also develop due to medicines containing testosterone and corticosteroids, contraceptive pills and medicines used to treat epilepsy.
Pseudo-acanthosis nigricans (acanthosis nigricans seen in overweight people) is a much more common condition, usually seen in people who are very overweight and dark-skinned. In this form of the disease, the skin in the folds is both thicker and darker than the surrounding skin, and there is usually excessive sweating in the affected areas. Pseudo-acanthosis is more common in women.
Diagnosis and treatment of acanthosis nigricans
For the diagnosis of acanthosis nigricans, investigations are carried out by the endocrinology department and treatment is attempted. The disease can usually be diagnosed by a dermatologist through physical examination and, where necessary, a biopsy. Although acanthosis nigricans cannot be fully cured, it may regress or lessen if the underlying cause of the disease is treated. Pseudo-acanthosis nigricans may clear or lessen with weight loss. Acanthosis nigricans caused by medicines may lessen or clear when the medicine is stopped. Treatment methods such as electrocautery, cryotherapy and laser are used for acanthosis nigricans appearing as fleshy growths.
Sarcoidosis
Sarcoidosis is a systemic granulomatous disease of not fully known cause that can involve any tissue or organ (granuloma: a nodule formed by cells of the immune system such as macrophages, lymphocytes and giant cells). Although the disease can be seen in any tissue or organ, the lungs and the lymph nodes inside the chest are most often involved, and it can appear in several organs at the same time.
Although the cause of the disease has not been fully established, it is known that a long-lasting, low-intensity antigenic stimulus activates the immune system and leads to the formation of granulomas. It has been suggested that infectious agents such as bacteria, viruses and parasites, or non-infectious agents such as beryllium, zirconium and pine pollen, may trigger this immunological process.
What are the symptoms of the disease?
This disease, which is more common in young and middle-aged people, has no diagnostic symptom or sign, and the patient's complaints can vary according to the organ involved. Many patients have no symptoms, and the diagnosis is made by chance on a chest X-ray. About 25-30% of patients have general symptoms of illness such as weakness, loss of appetite and fever. In some patients the disease can start acutely, with fever, joint pain, tiredness, weakness and the appearance of firm, painful, reddish-purple nodules on the front of the legs. In patients with lung involvement there are symptoms such as cough, shortness of breath, chest pain, wheezing and, rarely, coughing up blood. Sometimes enlarged lymph nodes in the neck, armpit or another area may be found on examination. Apart from the lungs, the disease is often seen in the eyes, and with eye involvement there may be symptoms such as redness of the eyes, blurred vision and sensitivity to light. With skin involvement, raised lesions of various kinds are found on the skin. Rarely, in patients with brain involvement, headache, dizziness and visual disturbances may appear. Patients with sarcoidosis have a higher risk of kidney stones than other people, and if stones are present, related urinary complaints and back pain appear.
Diagnostic approach in sarcoidosis
Although some patients have no examination findings, in patients with skin involvement the raised lesions on the skin may be noticed at the first examination. In the acute-onset form of the disease, erythema nodosum – a special form of skin involvement – together with complaints such as high fever, joint pain, weakness and tiring easily, immediately suggests sarcoidosis. Erythema nodosum is described as painful, reddish-purple raised nodules on the front of the legs, usually below the knee. Apart from sarcoidosis, it can also be seen in pulmonary tuberculosis.
The first step in diagnosing sarcoidosis is usually a standard chest X-ray. The chest X-ray may show enlargement of the lymph nodes on both sides and/or shadows due to disease of the lung tissue. Based on the changes seen on the chest X-ray, sarcoidosis is divided into 4 stages. In stage 0 disease the chest X-ray is normal. In stage I, II and III disease, respectively, enlargement of the lymph nodes of both lungs (bilateral hilar adenopathy), enlargement of the lymph nodes of both lungs together with signs of disease in the lung tissue, and signs of advanced disease in the lung tissue are found. When changes suggestive of sarcoidosis are seen on the chest X-ray, blood tests are requested, along with an eye examination, computed tomography of the chest, urine tests and lung function tests. Blood biochemistry shows raised calcium levels in some patients. Likewise, liver enzymes are raised in patients with liver involvement. In patients whose chest X-ray and chest CT show shadows due to disease in the lung tissue, lung function tests show a reduction. In patients in whom sarcoidosis is suspected on radiological and other laboratory methods, a biopsy is needed for a definitive diagnosis. Biopsy material can be obtained by bronchoscopic methods or from enlarged lymph nodes in the neck or armpit, from nodules in the skin, or from another organ involved outside the lungs (liver, muscle, lip mucosa, etc.). In some patients, mediastinoscopy is performed under general anaesthesia to reach the lymph nodes inside the chest and take a biopsy from them. In mediastinoscopy, after the patient is put to sleep, a small skin incision is made at the lower neck and upper chest, and an endoscope is inserted through it into the chest cavity. In this way, the lymph nodes in the middle of the chest and on both sides of the windpipe (trachea) are examined on screen and a biopsy is taken. The definitive diagnosis is reached by examining the tissue samples in the pathology laboratory.
Clinical course and treatment of sarcoidosis
There is a very close relationship between the clinical picture at diagnosis and the course of the disease. Acute-onset disease with rapidly appearing symptoms such as fever, joint pain and erythema nodosum usually regresses and heals on its own after a short time, while disease with a more insidious onset tends to become chronic. In patients with stage 0 and stage I disease on the chest X-ray, no treatment is needed if there is no involvement of other organs; these patients are followed up. Treatment is needed in patients with disease in the lung tissue and complaints such as cough and shortness of breath, and in patients with eye, kidney, brain, extensive skin or heart involvement. The great majority of patients recover spontaneously or with treatment. However, there is always a possibility that the disease will relapse after treatment. In the event of a relapse, the patient is re-evaluated and treated again.
Cushing's Syndrome
A health problem causing various changes in the body, resulting from excessive secretion of cortisol – a hormone secreted by the adrenal gland – for various reasons, or from taking too much of it from outside the body. Cushing's syndrome is a rare disease and is more common in women.
The most common cause of Cushing's syndrome is taking medicines containing cortisol (tablets, creams, injections) for any reason. Apart from this, it results from benign tumours of the pituitary gland (the small gland located at the base and centre of the brain that regulates the hormone-secreting glands), from substances secreted by various tumours – especially lung cancer – that stimulate the adrenal gland (ectopic ACTH syndrome), or from tumours of the adrenal gland itself secreting excess cortisol. Cases originating from the pituitary gland are called Cushing's disease.
Cushing's disease (pituitary tumours), the most common cause of Cushing's syndrome apart from medication, and adrenal adenomas, tumours of the adrenal gland, are benign tumours, but the excess hormone they secrete harms the body. Tumours outside the pituitary that secrete the hormone stimulating the adrenal gland (ACTH: adrenocorticotrophic hormone) are usually cancers. Very rarely, adrenal gland cancers (adrenal adenocarcinomas) cause Cushing's syndrome.
What are the signs and symptoms of Cushing's syndrome?
Weight gain, high blood pressure (hypertension), a moon-face appearance, fat deposits at the back of the neck, stretch marks on the skin, facial redness, excess facial and body hair in women, high blood sugar, weakening of the muscles and bones (osteoporosis), kidney stones, depression and sleep disturbance.
Palmar Erythema
The cause of redness and mottling of the palms, medically called palmar erythema, is not fully known. However, it is thought to arise from increased levels of oestrogen. It is found in 50-55% of pregnant women. It is less common in people of African descent. Rarely, it may also be found on the soles of the feet. It may cause no complaints at all, or there may be mild burning and itching. Regular use of moisturisers can help.
Because palmar erythema is an important sign of liver disease, it is advisable to carry out blood tests including liver function tests when it is present. Palmar erythema disappears after delivery as oestrogen levels return to normal.
Erythema Nodosum
Erythema nodosum consists of raised, red, warm, painful swellings the size of a hazelnut or walnut (usually 2-6 cm in diameter) that develop suddenly (acutely) in the skin on the front of the legs, usually at and below the knee, and on the feet. When they appear close to a joint, they can sometimes be confused with arthritis. Rarely, there is also a chronic and frequently recurring form. Erythema nodosum is a condition in which the skin over-reacts. It is a sterile inflammation of the fat tissue under the skin. It is very painful. It causes flu-like complaints such as fever, generalised body aches, joint pain and weakness. These painful red swellings never come to a head; this is how they differ from spots, abscesses, carbuncles or furuncles (carbuncles and furuncles are bacterial infections under the skin). Whatever the cause, the pathology is always a septal panniculitis (inflammation of the fat tissue). Only in erythema nodosum occurring in patients with Behçet's disease may there also be signs of inflammation of the vessel walls (vasculitis = perivascular infiltration). It usually clears without leaving a mark; lesions due to Behçet's disease can leave dark marks on the skin. For this reason, taking a biopsy from a patient with erythema nodosum for a pathological diagnosis is a largely unnecessary procedure. Erythema nodosum due to infection usually heals within 7 weeks even without treatment, but can sometimes last 5-6 months.
Erythema Annulare Centrifugum
Erythema annulare centrifugum (EAC) is a slowly progressing red lesion characterised by round shapes. Its incidence is reported as one in a hundred thousand. It can be seen at any age but is more common between 50 and 60, and it occurs equally in women and men.
EAC is regarded as a hypersensitivity reaction developing in response to something such as medicines, insects, food or malignancy. It is often seen together with fungal infections. Apart from these, viruses, parasites, medicines, foodstuffs, pregnancy, autoimmune hormonal disorders and malignancies can cause EAC. It may also be associated with gallstone infection, sarcoidosis and kidney infection . However, in the great majority of patients no cause is found.
EAC begins as a small, firm, red bump spreading from the centre outwards, and has two types: superficial and deep. Within a few weeks it reaches 5-6 cm in size, and the number of lesions may also increase . The superficial type takes the form of a red, non-firm patch. Scaling on the inner side of the advancing edge is characteristic, but is not always seen. In the deep type this is absent and the advancing edge is raised above the normal skin. It is seen most often on the trunk, arms and legs; the hands and feet are not involved. It mostly causes no complaints, although some patients may have itching. It can persist for weeks or months, but heals without leaving a mark.
EAC can be confused with other figurate erythemas, as well as with diseases such as cutaneous lymphoid hyperplasia, lymphoma, pityriasis rosea, annular urticaria, annular psoriasis, granuloma annulare, mycosis fungoides and tinea corporis. It is a chronic disease that can recur; in treatment, if there is a known underlying disease, this should be treated first. Even without treatment it often regresses on its own. However, in patients with many symptoms and widespread involvement, topical corticosteroids and calcipotriol can be effective . Sometimes a positive response can be obtained by treating fungal and other infections.
Sweet Syndrome
It was first described by Robert Sweet in 1964. It is a frequently recurring febrile skin disease, particularly in women. The age of onset is between 30 and 60. In adults it is three times more common in women than in men, while in children boys and girls are affected equally. It can be seen after feverish flu-like infections or together with blood diseases (leukaemia, lymphoma). It can accompany cancers of the stomach, bowel, breast, kidney and bladder.
When acute febrile neutrophilic dermatosis does not arise from a malignancy, it most often affects women between the ages of 30 and 50, with a female-to-male ratio of 3:1. In men it tends to appear at an older age (60-90 years). The disease may follow an acute respiratory illness, a gastrointestinal infection, medication use or an underlying malignancy. Histopathologically, there is dense neutrophil infiltration in the dermis with oedema in the upper dermis. It can result in vasculitis, but this is secondary.
Patients have a high neutrophil count and tender, dark-red plaques or papules, and are feverish. Rarely, bullous or pustular lesions may be seen. The lesions often appear in attacks. Each attack follows a fever and can last for days or weeks.
The diagnosis is made from the clinical features together with the result of a skin biopsy. A history of a preceding flu-like infection, an association with cancer or pregnancy, the presence of weakness and fever, and blood test results also help in making the diagnosis. 4 subtypes have been described:
1- Classic type (the most common)
2- Cancer-associated
3- Associated with inflammatory diseases
4- Pregnancy-associated
Symptoms
- Skin rash
- A red, hot swelling of the skin that is tender to the touch
- Redness of the skin
- Involvement of the neck
- Involvement of the arms
- Involvement of the face
Causes
Although its cause is unknown, it often appears together with an underlying malignancy, particularly haematological malignancies
Risk Factors
Acute respiratory illness, gastrointestinal infection, certain medicines
Treatment
Because flu-like infections play a part in triggering the condition in most of these patients, the picture regresses on its own once that illness has passed. Painkillers and corticosteroids can also be used in treatment. Patients over 50, those found to be anaemic on blood tests and those whose lesions develop fluid-filled blisters should be investigated for possible accompanying cancers.
Required Tests
- Full blood count (blood count + white cell differential)
- Biopsy
- Inspection
Possible Consequences
It can cause a high fever.
Pyoderma Gangrenosum
Pyoderma gangrenosum (PG) is a reactive neutrophilic dermatosis that may accompany inflammatory bowel diseases such as ulcerative colitis and Crohn's disease, lymphoproliferative diseases and rheumatological diseases. It is usually characterised by painful ulcerative lesions with a purplish border. The lesions are mostly located on the face, upper limbs and backs of the hands. The aetiology of the disease is unknown. Its subtypes are ulcerative, pustular, bullous and vegetative PG. The differential diagnosis of PG includes arterial and venous ulcers, bacterial and mycobacterial infections, vasculitides, malignancies, syphilis and Sweet syndrome. Although there is no definitive cure, topical and systemic corticosteroids and immunosuppressive medicines such as ciclosporin and methotrexate are used to treat PG.
Pyoderma gangrenosum (PG) is a destructive, necrotising, non-infectious skin disease with ulceration, seen most often in adults. Although it can be seen in any part of the body, it particularly involves the upper limbs and face. Lesions can arise secondary to trauma such as pathergy, infections, insect bites, biopsies and surgery, or on normal skin. The lesions take the form of painful ulcers, bullae, pustules or vegetations and are histologically characterised by an accumulation of neutrophils.
Generalised Pruritus
Persistent generalised pruritus can be a sign of many systemic diseases. The most important diseases that can cause pruritus are liver diseases (especially of the obstructive type), hepatitis C infection, kidney failure, hypothyroidism, hyperthyroidism, iron-deficiency anaemia, intestinal parasites, polycythaemia vera, malignant lymphomas (especially Hodgkin's disease), leukaemias, myeloma, solid organ malignancies and neuropsychiatric diseases. Diseases such as liver failure, uraemia, thyroid diseases and polycythaemia can be the precipitating cause in 20-30% of these cases. At least 10-30% of patients with Hodgkin lymphoma complain of pruritus, and in 7% it is the first sign of the disease. Pruritus accompanies 3% of patients with non-Hodgkin lymphoma.
Periorbital Oedema
Oedema occurring in the eye socket and the area surrounding the eye is called "periorbital oedema". Periorbital oedema can occur in the eyelids, the eye socket and any area around the eye. The treatment of oedema around the eye varies depending on its cause. Its main causes include infections of the face, allergic reactions and fluid retention by the body, but it can also appear as a sign of certain kidney disorders.
Oedema of the eyelid: Oedema of the eyelid, called periorbital cellulitis, which shows itself as swelling of the lid, is usually seen in children up to the age of 3. Oedema resulting from infections caused just under the skin by the bacteria Haemophilus influenzae, Streptococcus pneumoniae and Staphylococcus aureus has become much less common today because children are vaccinated against these bacteria.
Oedema of the eye socket and around the eye: Another type of oedema, seen outside the eyelid, is "orbital cellulitis". While eyelid oedema usually affects children, oedema of the eye socket can be seen in people of any age. It generally results from the bacterium Staphylococcus aureus spreading around the eye and causing infection. The infection mostly arises in the sinuses and spreads from there to the eye. Its symptoms include swelling and redness around the eye.