as most of the dm - specific cutaneous disorders are related to the duration of diabetes and chronic hyperglycemia , a study of cutaneous disorders in patients attending diabetic clinic was undertaken to know the impact of control of diabetes on the pattern of these disorders . a cross - sectional descriptive study of 500 consecutive patients attending diabetic clinic was conducted in a tertiary care hospital . patients who had not registered in diabetic clinic , either attending the dermatology clinic directly or referred from wards , were excluded from the study to ensure the uniformity in diabetes care received in diabetic clinic . a detailed history regarding age , gender , duration of dm , type of diabetes , and treatment taken for diabetes was taken . complete hemogram , urine analysis , fasting and postprandial plasma sugar tests were done in all the patients . serum creatinine , serum lipid profile , and fundus examination were also done to detect diabetic complications . the former was further divided into four categories : dermatoses with known pathogenesis , dermatoses without known pathogenesis , dermatoses that occur with increased frequency , and dermatoses due to diabetic treatment . the first two categories were correlated with gender , fasting plasma glucose ( fpg ) , duration of diabetes , and complications of diabetes like retinopathy , nephropathy , and peripheral neuropathy . test and chi - square test with 5% confidence interval ( p value 0.05 ) . males and females constituted 57.2% ( 286/500 ) and 42.8% ( 214/500 ) of cases with mean age of 58.211.96 and 53.310.78 years , respectively . the mean duration of dm was 5.55.8 years . in 82% of patients , the duration of diabetes was < 10 years . the mean fpg was 129.9748.65 mg / dl . in 60% of patients , fpg was < 130 mg / dl and it was 130 - 140 mg / dl in 12% of patients . general characteristics of diabetic patients with or without specific cutaneous disorders are compared in table 1 . systemic diseases such as hypertension ( 1.8% ) , ischemic heart disease ( 1% ) , and stroke ( 0.4% ) were present in 16 ( 3.2% ) patients . retinopathy was present in 14 ( 2.8% ) , nephropathy in 11 ( 2.2% ) , and peripheral neuropathy in 268 ( 53.6% ) patients . general characteristics of diabetic patients with or without specific cutaneous disorders among specific dermatoses with known pathogenesis , infections and signs of insulin resistance were common [ table 2 ] . among the fungal infections , tinea cruris was common ( 37.68% ) , followed by tinea corporis ( 18.84% ) , pityriasis versicolor ( 15.94% ) , candidal intertrigo ( 13.04% ) , tinea unguium ( 11.59% ) , candidal balanoposthitis ( 8.69% ) , candidal vulvovaginitis ( 4.34% ) , tinea pedis ( 1.4% ) , and tinea barbae ( 1.4% ) . among the bacterial infections , furuncles were present in 70.58% , folliculitis in 17.64% , and ecthyma gangrenosum , erysipelas , carbuncle , and cellulitis each in 2.94% of patients . dermatoses with known pathogenesis among the specific dermatoses without known pathogenesis , bullous diabeticorum was present in two ( 0.4% ) patients , and generalized granuloma annulare and diabetic dermopathy in one ( 0.2% ) patient each . among dermatoses that occur with increased frequency , vitiligo was present in eight ( 1.6% ) , lichen planus in nine ( 1.8% ) and psoriasis in three ( 0.6% ) patients . local insulin reaction such as erythema and induration was seen in four ( 6.2% ) patients , and nine ( 14.0% ) patients showed insulin lipodystrophy . apart from specific cutaneous disorders , various cutaneous disorders are related to diabetic complications such as microangiopathy ( diabetic dermopathy ) , glycosylation of proteins ( diabetic thick skin ) , neuropathy ( diabetic foot ) , immunologic dysfunction ( infections ) , insulin resistance ( acanthosis nigricans ) , and abnormal lipid metabolism ( xanthoma ) . fasting hyperglycemia is a main contributor to the overall diurnal hyperglycemia in poorly controlled diabetes . the results ( fpg<130 mg / dl ) of the present study showed well - controlled diabetes in the majority of patients attending diabetic clinic . also , the duration of dm was less than 10 years in the majority of patients . no statistically significant difference ( p>0.05 ) between the patients with or without dm - specific cutaneous disorders was noticed in the present study with particular reference to age and gender distribution , duration of dm , and fpg . this is mainly because the majority of specific skin disorders in the present study were acanthosis nigricans , acrochordon , and uncomplicated infections which are not related to chronic hyperglycemia ( discussed in detail below ) . there was no statistically significant difference between the occurrence of peripheral neuritis and various dm - specific cutaneous disorders . low prevalence of systemic complications in the present study may be due to shorter duration of dm . acanthosis nigricans and acrochordon , manifestations of insulin resistance which may be present before the expression of dm , were the predominant dermatoses with known pathogenesis . increased levels of insulin act on insulin like growth factor ( igf ) receptors , resulting in development of acanthosis nigricans . acrochordon has been regarded as a sign of impaired glucose tolerance , dm , and increased cardiovascular ( atherogenic lipid profile ) risk . the association between dm and increased susceptibility to infection in general is not supported by strong evidence . however , streptococcal , pseudomonas , and candidal infections are known to occur with increased frequency in dm . there are no conclusive evidences that diabetic patients are susceptible to dermatophytoses or staphylococcal skin infections . however , the patients especially with poorly controlled diabetes are at increased risk of severe and recurrent infections , and complications . as in nondiabetics , rate of exposure to the organisms seems to determine the occurrence of infections in diabetic patients . the predominance of infection in males in the present study may be due to increased likelihood of exposure to the infectious organisms and humid climatic and working conditions . the absence of diabetic thick skin and severe infections , and the lower incidence of specific dermatoses with or without known pathogenesis in the present study when compared to other studies[1012 ] [ table 4 ] is mainly due to difference in the diabetic population ( type 1 vs. type 2 ) , well - controlled diabetes , and shorter duration of dm in the majority of patients , and also the source from where patients were drawn , i.e. , diabetic clinic . in spite of about half of the patients having peripheral neuritis , only one patient had diabetic foot . comparison of specific cutaneous disorders with or without known pathogenesis , with other studies certain dermatoses with underlying autoimmune pathogenesis like vitiligo are known to occur in dm as a part of polyglandular autoimmune syndrome . however , such an association was not noticed in several other studies , including the present one . an association between psoriasis and increased cardiovascular risk and metabolic syndrome has been reported . while treating psoriasis patients , screening for metabolic syndrome and cardiovascular risk factors insulin reactions may be local ( erythema or urticarial pruritic nodules ) or systemic ( generalized urticaria , rarely anaphylaxis ) . the reactions are due to impurities in insulin preparations such as bovine or porcine proteins , additional peptides , preservatives , and additives . in the present study , similarly , lipodystrophy can be prevented by highly purified and recombinant insulin and injection site rotation . lower prevalence of insulin reactions in the present study may be due to the use of human insulin . the occurrence of nonspecific cutaneous disorders also has pathogenetic , prognostic , and therapeutic importance in diabetic patients . autonomic neuropathy or age of stratum corneum proteins has been attributed to the pathogenesis of ichthyosis , xerosis , and pruritus . the loss of cutaneous barrier in nonspecific disorders predisposes already susceptible diabetic patients to chronic and recurrent infections . while treating the dermatoses with underlying dm , three issues need to be kept in mind . usually , a prolonged systemic therapy is required because of chronicity and severity of dermatoses . patients with onychomycosis should be treated aggressively with oral antifungals to avoid devastating secondary bacterial infections . the second point is the interactions between the drugs used to treat dermatoses and oral hypoglycemic agents . therefore , blood glucose levels should be monitored carefully , and accordingly , the dosage schedules of antidiabetic treatment need to be adjusted . accelerated aging of skin has been reported in patients with both types of dm , especially type 1 . however , in the present study , such skin lesions ( seborrheic keratosis , senile comedones , senile purpura , solar elastosis , idiopathic guttate hypomelanosis ) are mainly due to chronologic and photo aging . the main goals of diabetic care are good glycemic control , physical exercise , medical nutritional therapy , diabetes self - management education , foot care , and early detection of nephropathy , retinopathy , and metabolic alterations . a good glycemic control definitely reduces the incidence and severity of cutaneous disorders with or without known pathogenesis , as observed in the present study . however , several nonspecific cutaneous disorders that occur in diabetic patients can increase the likelihood of exposure to infectious organisms and contact allergens , resulting in chronic and recurrent infections and eczemas , respectively . long - term effects of dm on the microcirculation and on dermal collagen eventually result in skin disorders in almost all the diabetic patients . thus , dermatologists play an important role in reducing the dermatologic morbidity , improvement of quality of life , and management strategy of diabetic patients . it is necessary to have a dermatologist in the diabetic clinic along with other specialists for early detection of potentially grave or predisposing conditions and to provide a comprehensive diabetic care to the patients .