HOW DIABETES AFFECTS BONES, JOINTS, MUSCLES, TEETH, AND SKIN | Added: 12, August 2017



DIABETES, BONES, AND JOINTS

What is arthritis?

The word arthritis is derived from the Latin via Greek word arthron (“joint”) and itis (“inflammation”). Arthritis is a disease in which a person’s joints become inflamed, most often resulting in joint pain and stiffness. There are more than 100 types of arthritis, some affecting the skin, muscles, bones, and internal organs, as well as the joints. For example, one type of arthritis is rheumatoid arthritis, in which the joint pain is caused by the immune system’s attack on the membrane lining the joints. Together, these types of arthritis are called rheumatic diseases and are considered to be one of the most common chronic health problems. (For more about immune system and inflammation, see the chapter “Diabetes and Body Connections.”)

Are people with diabetes more prone to arthritis?

According to the Arthritis Foundation, as of this writing, 47 percent of adults with arthritis also have another chronic condition. And of the 52.5 million American adults with arthritis, 16 percent (around 7.3 million) have type 2 diabetes, and 47 percent of adults with diabetes (both type 1 and type 2) have arthritis.

Are people with type 1 diabetes more prone to rheumatoid arthritis?

Many studies seem to indicate an association between rheumatoid arthritis and type 1 diabetes. According to the Arthritis Foundation, both conditions are autoimmune diseases, with inflammation as the common condition in both. In a person with type 1 diabetes, the insulin-producing pancreas is attacked, which means the person does not produce insulin. In a person with rheumatoid arthritis, the body attacks the tissues lining the joints. In addition, people who have rheumatoid arthritis have high levels of what are called inflammatory markers in their systems. For example, C-reactive protein, or CRP, is a marker that is also found in increased levels in people with type 1 diabetes.

Is there a connection between type 2 diabetes and osteoarthritis?

Some researchers believe there is a connection between people with type 2 diabetes and osteoarthritis, but it is not because of inflammation, as with type 1 diabetes and rheumatoid arthritis. Because it is estimated that up to 80 percent of people with type 2 diabetes are overweight or obese, the additional weight puts stress on the joints, especially those of the lower body. In addition, the pancreas has to produce more insulin to compensate for the excess glucose in people with type 2 diabetes. This means the heart and blood vessels are stressed, causing problems with blood flow to joints. Because of these added stressors on the joints, osteoarthritis of the knee and hip are often found in people with type 2 diabetes.

How are musculoskeletal problems in the body connected to glucose?

The term musculoskeletal means something that is connected to both muscles and bones in the body. It usually implies the range of motion in the hands, wrists, shoulders, and other joint areas and concentrates on the connective tissues surrounding the joints. According to Harvard Medical School and the American Diabetes Association, many musculoskeletal complications stem from changes in these connective tissues, including in people who have diabetes. These complications should not be confused with osteoarthritis (see above) but mostly appear to result from the attachment of glucose to the connective tissues. This often results in the stiffening of joints all over the body.

What hand problems do people with diabetes sometimes face?

Many people with diabetes face musculoskeletal problems, especially of the hands. For example, diabetic stiff hand syndrome (or diabetic cheiroarthropathy) is a disorder that causes the skin on the fingers to become thick, tight, and waxy, thus causing the fingers-and often the entire hand-to become limited in movement. Usually, the first sign is a problem keeping the fingers together without leaving a gap (it is often called a “prayer sign”). It is thought to be caused by several reasons, including consistently high blood glucose levels that cause excess collagen (a structural protein that literally holds the body together) in the skin. At this writing, there is no cure for the syndrome.

Why is arthritis often connected to foods a person eats?

Arthritis appears to be an ailment that is affected by what a person eats. Many studies indicate that some foods, such as processed or fried foods, cause more inflammation in our bodies. Foods such as fresh vegetables and fruits, along with nuts and teas, can cut back on the inflammation that affects a person’s arthritic joints.

Flexor tenosynovitis-also called trigger finger-is an inflammation of the finger tendons that makes them hard to move.

Another problem with the hands-again in the fingers-is called trigger finger, or flexor tenosynovitis. This occurs when the tendon (and the sheath around it) that extends into the finger or thumb becomes inflamed. Lumps (nodules) can form on the tendon, causing it to stop moving correctly through the sheath and stopping the finger from moving. This causes the finger to become locked in a bent or straight position, thus the term trigger finger.

Yet another hand problem for many people with diabetes has to do with the tissue under the skin of one or both palms. Dupuytren’s contracture is when the palm’s skin becomes thicker and tightens. If left to thicken over several years, it can lead to pain, stiffness, and the inability to straighten the finger joints, especially affecting the middle and ring fingers. Certain treatments are often suggested, including surgery to break apart the thick tissues or injections of steroids into the palm.

Do people with diabetes have more problems with carpal tunnel syndrome?

One of the more well-known musculoskeletal wrist problems for people with diabetes-and those who do not have diabetes-is called carpal tunnel syndrome. It is caused by the thickening or swelling of the tendons found in the wrist, which compress the nerve that runs from the forearm into the hand. The most common symptoms include burning, shooting pains, and numbness in the hand and/or the wrist. It is mostly caused by repetitive movement (and thus called a repetitive injury) for most people. It is estimated that up to 20 percent of people with diabetes experience carpal tunnel problems, primarily because their nerves are more sensitive to compression from a repeated motion. (For more about nerve damage and diabetes, see the chapter “How Diabetes Affects the Nervous System.”) For many people, the treatment can include steroid injections to reduce inflammation and physical therapy. But for more severe cases, surgery is often suggested to cut the connective tissue that is putting pressure on the nerve.

What shoulder problems do people with diabetes sometimes face?

People with diabetes often face a musculoskeletal problem with their shoulders called adhesive capsulitis, or frozen shoulder. This occurs when the shoulder gradually stiffens, causing pain and decreasing the joint’s range of motion. Although it is not fully understood what causes a frozen shoulder, it is usually found in association with other musculoskeletal problems, such as in people with diabetes (especially those who have such diabetic-related conditions such as retinopathy and neuropathy), thyroid disease, or certain autoimmune diseases. Frozen shoulder can be difficult to treat. The most common treatments range from administering medications for pain (such as nonsteroidal anti-inflammatory drugs [NSAIDs] or corticosteroid oral medications [for example, prednisolone] or corticosteroid injections in the joint), physical therapy for stretching the joint, and/or arthroscopic surgery to cut the adhesions that are usually involved in restricting the joint’s mobility.

What recent study indicated that diabetes may be linked to tendon pain?

It is known that chronically high blood glucose levels can increase the risk of developing tendinopathy, a condition that commonly causes the tendons to thicken. If a person has tendinopathy, then he or she usually has painful and inflamed tendons when exercising or with movement and, in particular, in response to overuse. A recent study showed there may be a link between type 2 diabetes and tendon pain. The researchers discovered that people with diabetes are more than 3.5 times as likely as those without diabetes to have tendon pain (and if severe, tendinopathy) in any tendon of the body. They also found that those with tendinopathy were 1.3 times more likely to have type 2 diabetes. The study also showed that the risk of tendinopathy also increases with the number of years a person has diabetes.

Is there a connection between diabetes and bone fractures?

There is evidence that people with both type 1 and type 2 diabetes have a higher incidence of bone fractures than the general population. In fact, although people with type 2 diabetes usually have above-average bone density (carrying around extra weight helps maintain bone density, as does weight-bearing exercise), they still have more bone fractures. For example, two recent studies showed that people with type 1 diabetes had a risk of hip fracture 6.3 to 6.9 times higher, and those with type 2 diabetes 1.4 to 1.7 times higher, compared with people without diabetes. The reasons for these bone fracture and diabetes connections are unknown.

Why is osteoporosis associated with bone fractures?

Osteoporosis is a bone disease that causes an increase in the risk of fractures and breaks, usually in older adults. Osteoporosis occurs when the person’s bone mineral density decreases, causing the bones to deteriorate. This deterioration causes a loss of bone strength, lower bone mass, and a higher risk of fracturing the bones of the hip, spine, and wrist. In advanced osteoporosis, the bone is literally porous, with small holes altering the bone structure, which allows the bones to break more easily. (For more about osteoporosis, see the chapter “Who Gets Diabetes?”) According to the most recent data, it is estimated that around 10 million Americans have osteoporosis. It is considered to be the most common type of bone disorder in both females and males, although more females experience the disease.

But there are several theories. One suggestion is that most people with type 2 diabetes are overweight or obese, making balance and coordination more difficult. Thus, people with diabetes and larger body size (and high bone mass) may have higher fracture rates because of balance problems. In addition, many people with diabetes (type 1 and type 2) have peripheral neuropathy and/or vision problems, making them more likely to fall and fracture a bone. And if a person with diabetes (type 1 or 2) experiences a hypoglycemic (low blood glucose) episode, he or she may fall and fracture or break a bone, as low blood glucose causes the person to be confused or even pass out.

DIABETES AND MUSCLES

How many muscles are in the average human body?

Most research says there are about 650 muscles in the average human body, although the numbers vary from one person to another. But other scientists believe there may be as many as 850 muscles, depending on how you categorize and look at each muscle group.

What are the three main types of muscle tissue?

The three main types of muscle tissue are as follows:

Smooth muscles-found in the walls of blood vessels, in the walls of major organs (digestive, respiratory, urinary, and reproductive tracts), and in the iris of the eye.

Cardiac muscles-as the name implies, found only in the heart; they are responsible for pumping blood throughout the body.

Skeletal muscles-attached to tendons, which, in turn, are attached to bones; they help with the movement of the body.

Where are sources of energy stored for muscle cells?

The muscle cells that make up the body’s muscles use various sources to power their contractions. For example, if they need quick energy, they can use stored molecules in the cells (called ATP and creatine phosphate), which are usually depleted after about 20 seconds of activity. Then the muscles switch to other sources, especially glycogen (a carbohydrate made up of a string of glucose molecules). It is glycogen that helps the body make it through workouts-whether a person is lifting weights or running-and glycogen originates with the foods a person eats. The following lists the major sources of energy for the body’s systems and where the sources are stored in the body:

Adenosine triphosphate (ATP) is a chemical that helps store energy in cells, including muscle cells, which can use the energy to contract.

Body System Sources of Energy

Source

Storage Site

Carbohydrates

Glycogen; there is an average of 500 grams stored most of the time in the average human, mainly in the liver and skeletal muscles.

Fats (lipids)

Adipose tissue (although it has several other tasks) stores energy in our system as fats (in the form of triglycerides); it is estimated that a healthy adult male has 12 to 18 percent body fat, while healthy adult females carry about 12 to 25 percent body fat.

Protein

Found throughout the body; usually the body’s last choice as an energy source.

In general, what are the processes the body uses to maintain energy-especially glucose?

When a person is not eating or is exercising, the body must draw on its internal energy stored in various places. The major source is glucose, but the body follows several steps in order to obtain this energy:

Glycogenolysis-This is the process that occurs when the body breaks down carbohydrates, or glycogen, into simple glucose molecules.

Lipolysis-This is when the body breaks down fats into glycerol and fatty acids. Gluconeogenesis-This is a multistage process in which amino acids are used to make glucose.

Fatty acids-If there is no gluconeogenesis, the body can break fatty acids down directly to get energy.

What is muscle mass, and can it be affected by diabetes?

Muscle mass is usually interpreted as the amount of skeletal muscle in the human body. And yes, it can be affected by diabetes. In particular, people tend to lose muscle mass as they age. If an older person also has diabetes, he or she tends to lose muscle mass much faster than people without diabetes of the same age. Because of this, the American Diabetes Association recommends that people with diabetes partake not only in regular aerobic exercise but also in strength training at least twice a week if possible. In the majority of cases, this will not only help increase muscle mass but also improve the person’s blood glucose levels.

Does muscle mass affect glucose?

There appears to be a link between glucose and muscle mass. In general, in response to insulin, skeletal muscles use glucose in the bloodstream for energy. For some people, this is good news, as it balances the amount of insulin in their system. This is also why exercise is so important to lower the risk of developing diabetes. (For more about exercise and diabetes, see the chapter “Diabetes and Exercise.”)

DIABETES AND TEETH

Can the gums be an indicator of diabetes?

Yes, in some people with diabetes, one of the more insidious and “hidden” signs of the disease is often red, tender, and/or swollen gums. It is estimated that nine out of ten people with gum disease are at high risk for diabetes, compared to six out of ten who do not have gum disease.

What are some signs of gum disease?

One of the first possible signs is called gingivitis, or when the gums become inflamed and sensitive or tend to bleed, especially while a person is brushing the teeth. Gingivitis is usually caused by the buildup of plaque-or a combination of food, bacteria, and mucus, a mix that attaches to the gums and teeth (it is usually seen as an off-white soft layer, usually at the gum line). If the teeth are not properly cleaned and the plaque removed-which is why visiting the dentist regularly, especially for a person with diabetes, is necessary-then this plaque can harden into calculus, a hard substance resembling whitish plaster, that can form at and under the gum line. Calculus can irritate and infect the gums, eventually leading to periodontitis, an irreversible disease that is often thought to account for more tooth loss than dental cavities.

Dental problems are even more important to keep track of when one has diabetes because they can be precursors to even more serious health issues.

Why is it important for a person with diabetes to be aware of tooth pain?

A person with a toothache from tooth decay is most often actually experiencing problems-including infection-with the tooth’s pulp, or the inner structure in which the blood vessels and nerves reside. When the decaying tooth is exposed to hot or cold foods or drinks, the person usually feels a great deal of tooth pain. The solution is usually to remove the tooth pulp to stop the infection from reaching the bone that holds the tooth in place (in a procedure called a root canal). If not caught in time, tooth decay can lead to root decay and also destroy the bone. If the bone does become involved, then it can cause the tooth to loosen or even abscess (an internal infection usually below the gum line), with the affected tooth needing to be extracted.

For a person with diabetes, keeping track of tooth pain is even more important. Because diabetics often have higher blood sugar levels, the sugar keeps their immune system from fighting off infections the way it should. In addition, because high glucose levels tend to narrow blood vessels, the sugar can reduce blood flow, or circulation to the tooth, slowing down healing. Thus, once such a tooth infection starts, it is often harder for a person with diabetes to fight it off. (For more about diabetes and the immune system, see the chapter “Diabetes and Body Connections.”)

DIABETES AND THE SKIN

What are the major functions of the skin?

The skin is considered the largest organ in the human body. It has several major functions, including:

Hydration-The skin provides protection from both injury (such as cuts or abrasions) and dehydration (water loss). Because the outer skin cells are dead, the skin is waterproof enough to prevent water loss and to prevent water from entering the body when a person is immersed.

Barrier-The skin is a barrier against invasion by bacteria and viruses and is involved in the regulation of body temperature.

Vitamin D-The skin is also the organ responsible for the synthesis of a form of vitamin D. A substance called 7-dehydrocholesterol forms from cholesterol in the wall of our intestines. When the sun’s ultraviolet radiation strikes the surface of the human skin, it causes the 7-dehydrocholesterol that reaches the skin’s surface to form cholecalciferol, or vitamin D-3.

Does the average person’s skin vary in thickness?

Yes, the thickness of a person’s skin varies, depending on where it is found on the body. Skin averages 0.05 inches (1.3 millimeters) in thickness, and most of the body is covered by thin skin, which is 0.003 inches (0.08 millimeters) thick. The thinnest skin is found in the eyelids and is less than 0.002 inches (0.05 millimeters) thick, while the thickest skin is on the upper back (0.2 inches or 5 millimeters).

Touch-The skin contains receptors that receive the sensations of touch, vibration, pain, and temperature. In fact, for many people with diabetes, the skin’s touch is most often affected, as high blood glucose levels can damage the nerves in the skin.

Why should people with diabetes pay particular attention to their skin in the summer?

For a person with diabetes, the summer heat can cause certain problems with the skin. For anyone, heat can cause more sweating, and moisture can get trapped in the folds of skin or between a person’s toes. This excessive moisture can cause more of a problem for a person with diabetes, as bacteria feed off the sugar-concentrated skin cells, and this bacteria growth, in turn, can lead to infections. In addition, dry skin is often a problem in the summer (and sometimes in the winter with dry, inside heat). If a person’s diabetes is not under control and he or she has too much glucose in the bloodstream, then it is difficult for the body to retain moisture. When this happens, the skin can become dry and cracked, often leading to infection. Thus, health care professionals suggest that one of the best ways for a person with diabetes to help his or her skin in the summer (or in any season) is to keep the blood glucose under control. (For more about diabetes and being outdoors, see the chapter “Taking Charge of Diabetes.”)

What is diabetic dermopathy?

Much like age spots, diabetic dermopathy causes light-brown, scaly patches to form on a person’s skin. They are also called “shin spots,” as they most often form on the shins. These spots usually occur in people who have diabetes and are over 50 years old. They have also been associated with heart disease-which means a person with diabetes and such spots should mention the patches to a health care provider.

Is there a connection among psoriasis, obesity, and diabetes?

According to a 2016 Danish twin study (in which all the participants were twins), there seems to be a link among psoriasis, obesity, and diabetes. Psoriasis is a chronic skin condition in which the skin is inflamed and breaks out in red-and-pink itchy patches. The researchers looked at the participants’ psoriasis conditions, along with their body mass indexes (or BMI, which usually indicates whether a person is obese or not; for more about BMI, see the chapter “Diabetes and Obesity”) and diagnosis of type 2 diabetes. The results indicated that there appears to be an association among the three conditions, but the cause of the connection is still unknown. Some researchers suggest that psoriasis could lead to a sedentary lifestyle (people with the skin condition are often afraid to go out into the public), which can lead to obesity and diabetes. Another suggestion is that diabetes and obesity could cause skin inflammation, eventually causing psoriasis.

Should people with diabetes use antibacterial soap to clean their skin?

For most people, keeping their skin clean is necessary to fight dirt, grime, and certain bacteria. In the case of insulin-dependent diabetes (mainly people with type 1) diabetes, keeping the skin clean at an injection site is necessary. But all skin normally has some type of bacteria, and many of those bacteria help us fight off disease and infection. Thus, keeping skin clean is good, but not necessarily by using antibacterial soap. Most health care professionals suggest that using regular soap is enough and that thorough and consistent hand washing is truly what keeps away infection, not antibacterial soap.

Many experts believe the overuse of antibacterial soap may eventually help lead to a proliferation of antibiotic-resistant bacteria. In fact, in late 2016, the Food and Drug Administration (FDA) banned the use of certain chemicals found in antibacterial soap. They found data that suggested long-term exposure to certain active ingredients used in antibacterial products-for example, triclosan (liquid soaps) and triclocarban (bar soaps)-could pose health risks, such as bacterial resistance or hormonal effects. Thus, the FDA ruled that over-the-counter consumer antiseptic-wash products containing certain active ingredients can no longer be marketed.

Do certain diabetic medications affect the skin?

Yes. For example, glipizide, a common diabetic medication classed as a sulfonylurea, can make the skin more sensitive to sunlight. Because of this, many dermatologists and other health care professionals suggest that a person with diabetes who is on certain medication similar to glipizide wear sunscreen with an SPF of 30 or higher. Some dermatologists suggest an even higher SPF number, especially if the person is fair skinned.

What skin problems are often experienced by people with diabetes at injection sites?

People with diabetes who rely on insulin injections should watch their injection sites for signs of infection. But two other common skin problems often accompany injections. Lipoatrophy and hypertrophy are two main skin problems at insulin-injection sites. Lipoatrophy occurs when the fatty tissue that lies under the skin essentially sinks, causing dents or dimples in the skin at injection sites (it somewhat resembles cellulite but on a smaller scale). It is thought that lipoatrophy may be caused by the body’s immune reaction. In other words, the body believes the insulin is a “foreign” substance, and the immune system responds. In most cases, the problem does not occur if the person with diabetes is using highly purified insulin and preferably human insulin.

Because certain diabetes medications can make your skin more sensitive to sunlight, protecting skin from the sun is critical. Wear a strong sunscreen when planning to be outdoors during the day for an extended time.

Hypertrophy occurs when the body’s cells-most often fat cells-become overgrown, creating lumpy skin at the injection site that often resembles scar tissue. In this case, it is not the body’s immune system responding to the insulin but a physical response to using the same injection site over and over. The condition is also called lipohypertrophy. When a site is used so many times, fat deposits accumulate in that area. Such a site may be more “comfortable” to use because hypertrophy can cause the area to become numb. However, the lumps that form are caused by abnormal cell growth and can diminish the absorption of insulin at that site. (For more about insulin, see the chapter “Taking Charge of Diabetes.”)

Can the two major skin problems around injection sites be prevented?

Many people with diabetes who inject insulin may prevent lipoatrophy and hypertrophy to some extent by rotating the location of the injection sites. Some researchers also believe that both skin problems may be caused by the type of insulin used. Thus, if a person with diabetes experiences either of these problems, then he or she may want to talk to the primary-care physician about the insulin used. (Note: It is also often recommended that a person with diabetes have his or her injection sites checked by a health care provider now and then for possible infection and these two skin problems.)

What are diabetic foot ulcers?

Diabetic foot ulcers, or diabetic foot sores, are open sores or wounds that are most commonly located on the bottom of the foot. They develop for a number of reasons, including the lack of circulation and feeling in the foot from peripheral neuropathy (such that the wound often goes unnoticed); foot deformities; friction or pressure that irritates the foot; trauma to the foot; and having diabetes for a long time. With a lower blood flow in the feet and higher blood glucose levels (both due to diabetes), the body’s ability to heal is reduced, increasing the possibility of infection and foot ulcers.

Foot ulcers are more prevalent in Native Americans, African Americans, Hispanics, and older men, especially those who have diabetes. People with diabetes who use insulin, and those with diabetes-related heart, kidney, and eye disease, are also at a higher risk to develop foot ulcers, as are those who are overweight and/or smoke. Thus, most health care professionals suggest that a person with diabetes check his or her feet every day for possible injury. If an ulcer is found, seek medical care immediately to reduce the risk of infection. (For more about diabetes and foot problems caused by nerve damage, see the chapter “How Diabetes Affects the Nervous System.”)

Diabetics are more prone to foot ulcers. If left untreated, they can become seriously infected and result in partial or full amputation of the foot.

How are foot ulcers treated?

Health care professionals treat foot ulcers in several ways. When such an ulcer is found, the treatment includes taking pressure off the area of the foot that has the ulcer. It may also include gently removing some of the dead skin and tissue from the foot and applying a medication or dressing to the ulcer to help prevent infection. In addition, there will no doubt be a concentrated effort to manage the person’s blood glucose levels and other health problems, all of which could exacerbate the ulcer. And although not all ulcers will be infected (especially if noticed and treated right away), those that are infected may need a treatment of antibiotics, wound care (several hospitals have such wound-care facilities), and, if severe enough, hospitalization.

How can a person with diabetes keep a foot ulcer from becoming infected?

There are several ways to try to keep a foot ulcer from becoming infected. The most important way is for people to keep their blood glucose levels stable. If they notice an ulcer, after consulting their health care professional to let them know about the ulcer, it is best to keep the wound clean and bandaged. They should also clean the wound daily and change the bandage or dressing-and avoid walking barefoot, especially outdoors or around the home (dust and dirt can enter and infect the ulcer). If the wound is on the bottom of the foot and being tended by a health care professional, the patient may be asked to wear special footwear to reduce the pressure and irritation to the ulcer area.

What are the connections among diabetes, foot ulcers, and amputations?

According to the American Podiatric Medical Association, it is estimated that around 15 percent of people with diabetes experience some type of foot ulcer. Of these people, around 6 percent will be hospitalized because of infection and other ulcer-related complications. They also further estimate that around 14 to 24 percent of people with diabetes who develop a foot ulcer will eventually require an amputation and that foot ulceration precedes 85 percent of diabetes-related amputations.

What should a person with diabetes do to keep track of potential foot problems?

Because people with diabetes often experience nerve damage in their feet from peripheral neuropathy and/or peripheral artery disease (for more about peripheral neuropathy, see the chapter “How Diabetes Affects the Nervous System”) or from unnoticed injuries, it is important to check their feet daily (top and bottom, including between the toes) for possible injury. Besides the obvious other rules for maintaining foot health-especially keeping blood glucose levels balanced and maintaining a healthy weight-the American Podiatric Medical Association and other groups involved in helping people with diabetes suggest a daily foot exam that entails the following:

Check feet for extremes in temperature, either very cold or hot. Keep feet clean by washing them each day. And keep them dry, especially between the toes, after showering, bathing, or swimming or on hot, humid days.

Examine the skin on the feet (top and bottom) for ulcers, calluses, sores, blisters, dried or cracked skin that doesn’t heal well, or any other unusual skin conditions, especially between the toes. If the person finds it difficult to see the bottom of his or her feet, it may help to use a mirror on the floor or ask a friend or family member for assistance.

Do not try to remove calluses, corns, or warts on a foot, as over-the-counter products can burn the skin (most contain salicylic acid) and cause an infection, especially for people with diabetes. Ask a health care professional for help with any such skin problems on the feet.

Do not wear tight socks or pantyhose. When socks, pantyhose, or sandals are removed, check them for blood, which indicates a cut or wound on the foot.

Maintain footwear (shoes and socks) in good condition and, if possible, have new shoes properly measured so they fit well. There are also special types of socks (most are seamless) for people who have diabetes, usually found in drugstores, as well as some medical supply centers and hospital pharmacies.

Exercise helps maintain weight and increases the circulation to the feet, but always wear the best-fit athletic shoes or sneakers when exercising. If there are other problems with a foot (or feet), such as bunions, hammertoes, or an internal structural injury, then consider orthotic insoles in shoes and sneakers that are made especially for people with diabetes.

Be aware of improper fit, irritating seams, or tears in footwear that can irritate the skin. Before putting shoes or sneakers on, check for pebbles or other objects that may rub the skin, causing a wound.

Try not to go barefoot, especially outside, where objects may injure a foot and lead to infection.

Test water temperature with an elbow before entering a bath or hot-water soak to prevent burns. Also be aware of potential burns when putting feet near a fireplace, fire pit, grill, radiator, or any other heat source.

Look for thin, fragile, or shinny skin, which may indicate a decrease in circulation in the feet, especially the toes.

Check around the toenails for ingrown nails, splits or thickening of the nail, or fungal infection (such as athlete’s foot-see below). Ask a health care professional for the best way to maintain nails on the hands and feet to prevent problems.

Check for signs of neuropathy, meaning loss of sensation in any extremity-feet, toes, hands, or fingers.

See a health care professional and discuss possible problems that a person with diabetes can have in terms of extremities. If possible for maintenance of the feet, see a podiatrist (the letters “DPM” after the name indicates a doctor of podiatric medicine) twice a year to help with foot care, as most are trained to treat foot conditions caused by diabetes, such as wounds, infections, peripheral neuropathy, and ulcers.

Should a person with diabetes be aware of athlete’s foot?

Yes, a person with diabetes should be aware of problems associated with athlete’s foot, also called tenea pedis. It is considered to be a skin fungus, with the common name of ringworm (although it is not caused by a worm, and it does not involve a worm in any way). Many times it is associated with dogs and cats and can be very contagious, whether from human or animal. The symptoms of this skin fungus are scaling, itchy, flaky skin. It is usually associated with the toes, but it can extend to the bottoms of the feet. It thrives when the feet are hot and sweaty, especially if a person wears nonbreathable instead of breathable shoes and socks. It can also spread in public places; for example, it can be found on the floors of saunas, swimming pools, locker rooms, shower stalls, and washrooms-or places that are associated with humidity and people walking barefoot.

Athlete’s foot is considered to be common in people with diabetes. It can usually be prevented by daily washing and drying of the feet, wearing sandals in public places such as swimming pools, and by wearing breathable shoes and socks. Although it is often diagnosed as just flaky skin, the problem for people with diabetes is not only the possibility of eventual infection in the area but also a secondary bacterial infection called cellulitis. This noncontagious infection occurs most often because of poor circulation in the extremities and weakened immune systems associated with diabetes, causing redness, swelling, and tenderness in the infected area. Antibiotics and anti-fungal creams or ointments are often prescribed, but if the cellulitis is not treated in time, it can lead to serious infections in the foot and lower limbs and, in the most extreme cases, to amputation.

Even a common and relatively minor affliction such as athelete’s foot can turn serious for a diabetic, who can develop serious infections.

DIABETES, HAIR, AND NAILS

How many hairs are on the human body, and where are most located?

On the average human body, there are approximately five million hairs. Males have a few hundred thousand more hairs than women. In males and females, hormones are responsible for the development of such hairy regions as the scalp, the axillary (armpit), and pubic areas, and, in addition in men, on the chest. Overall, the various types of hair grow all over the human body except for the soles of the feet, palms of the hand, eyelids, and lips.

Does diabetes affect a person’s hair?

In many cases, diabetes can affect a person’s hairs-on the head, arms, legs, eyelashes, eyebrows, and other parts of the body-especially the loss of hairs. The hairs of an average adult without diabetes usually go through an active growth phase (two years or more, growing about 0.39 to 0.79 inch [1 to 2 centimeters] per month). Next is a resting phase (for a little over three months), and from there, some of the resting hairs fall out. But if a person has diabetes, these three phases are disrupted, with slower hair growth and/or more hair loss after the resting phase. This is most often caused by poor circulation to the person’s scalp, which can cause hair loss and slow down hair growth.

Diabetes can also cause excess stress on a person’s body, leading to hair loss. Hair loss can also be caused by medicines to treat diabetes, as well as by other chronic illnesses, such as thyroid disease.

What is alopecia areata?

Alopecia areata often occurs if a person has diabetes (“alopecia” is the medical term for baldness). In this case, the immune system of the person attacks the hair follicles, causing the hairs all over the body or in specific spots to be lost in patches. This most often occurs in people with type 1 diabetes. Although type 2 diabetes is not thought of as an autoimmune disease like type 1, cases of alopecia areata have also been reported. Research also suggests a genetic component to this condition. In many cases, if a family member has alopecia areata, then others in the family have a higher risk of developing the condition. And if the family member also has an autoimmune disease, such as thyroid disease, lupus, or diabetes, then relatives may have an even higher risk of developing alopecia areata.

How many hairs does the average person have on his or her head?

The amount of hair on the head varies from one individual to another. An average person has about 100,000 hairs on the scalp (blonds 140,000, brunettes 155,000, and redheads only 85,000). Most people shed between 50 to 100 hairs daily.

What are Beau’s lines?

The side-to-side, deep, grooved lines or ridges on a person’s fingernail or toenail are called Beau’s lines. This condition was named after French physician Joseph Honoré Simon Beau (1806–1865), who first described the condition in 1846. The lines are often caused by a trauma to the nails, medications, and treatments for certain diseases (such as chemotherapy). It is also an indicator of diabetes. They are often found on the nails of a person with diabetes and/or a person who is at risk for developing diabetes (it is often seen in people with uncontrolled blood glucose levels).

Do people with diabetes have more toenail problems?

Most people with type 1 or type 2 diabetes have more problems than others with their toenails, including ingrown toenails, a fungus, or even foot ulcers. This is often due to the person’s not noticing a problem with a toenail, mainly because diabetes causes nerve damage (he or she cannot feel the problem) and poorer circulation in the extremities. In addition, the person may also develop toenail fungus, meaning the nail becomes yellow and thick. If not treated, such a fungus can lead to a bacterial infection, which is often difficult for a person with diabetes to fight. This is why people with diabetes should check their feet and toenails regularly. And if a toenail problem is noticed, then a health care professional (including podiatrists, who are familiar with treating people with diabetes) should be consulted.

Why do some people with diabetes have nails with bumps or ridges?

Bumps or ridges on a fingernail or toenail often indicate a previous injury to the nail, such as a blow (for example, accidentally hitting the fingernail with a hammer). They can also occur in the normal aging process or if a person is malnourished. If a person has diabetes, the nails may also have a profusion of bumps and ridges, mainly because of there is less blood flow to the extremities and/or poorly controlled blood glucose levels.

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