Journal of Cosmetics, Dermatological Sciences and Applications, 2012, 2, 141-143
http://dx.doi.org/10.4236/jcdsa.2012.23028 Published Online September 2012 (http://www.SciRP.org/journal/jcdsa)
141
Scleredema Diabeticorum in a Patient with the Normal
Range of the Hemoglobin A1c Level and Impaired Glucose
Tolerance
Hiromasa Matsuda1, Naoki Oiso1*, Yukie Fujita2, Hiroshi Ikegami2, Akira Kawada1
1Departments of Dermatology, Kinki University Faculty of Medicine, Osaka, Japan; 2Departments of Endocrinology, Metabolism
and Diabetes, Kinki University Faculty of Medicine, Osaka, Japan.
Email: *naoiso@med.kindai.ac.jp
Received May 7th, 2012; revised June 13th, 2012; accepted June 28th, 2012
ABSTRACT
Scleredema diabeticorum is an uncommon skin disorder showing a diffuse, symmetrical, and non-pitting persistent in-
duration developing initially on the nape. It usually occurs in patients with poorly controlled or insulin-resistant diabetes
mellitus. We present a 57-year-old woman with scleredema diabeticorum with hemoglobin A1c 6.1% (normal, 4.7% -
6.2%) and impaired glucose tolerance. Alcian blue staining at pH 7.0 illustrated deposits of acid mucopolysaccharides
between the collagen bundles in the reticular dermis, but the staining at pH 1.5 did not show the deposits. This case in-
dicates that scleredema diabeticorum may be an early indicator of undiagnosed diabetes mellitus in some cases, and that
impaired glucose tolerance test should be performed for individuals with scleredema even though the hemoglobin A1c
level is within the normal range.
Keywords: Scleredema Diabeticorum; Alcian Blue Staining; Diabetes Mellitus; Hemoglobin A1c; Impaired Glucose
Tolerance; An Early Indicator
1. Introduction
Scleredema diabeticorum, a rare disorder of unknown etio-
logy, is characterized by a diffuse, symmetrical, and non-
pitting persistent induration of the skin [1]. It first ap-
pears on the nape of the neck and then on the shoulders
and back. It is commonly preceded by long-existing, poor-
ly controlled diabetes mellitus [1]. Here, we present a 57-
year-old woman with scleredema diabeticorum associ-
ated with impaired glucose tolerance.
2. Case Report
A 57-year-old woman visited us with a slowly develop-
ing asymptomatic eruption on the nape. She had first no-
ticed it three months earlier. A physical examination re-
vealed the presence of an ill-defined, non-pitting, indura-
tion on the nape (Figure 1). She had not been diagnosed as
having diabetes. She had no recent episode of infectious
disorders. Laboratory blood test results were hemoglobin
A1c (HbA1c): 6.1% (normal, 4.7% - 6.2%); total choles-
terol: 228 mg/dl; triglyceride: 122 mg/dl; highden-
sity-lipoprotein cholesterol: 51 mg/dl; anti-hepatitis B sur-
face antibody: negative; anti-hepatitis C virus antibody:
negative; anti-human immunodeficiency virus type I
(HIV-I) antibody: negative; and anti-HIV-II antibody:
negative. We did not examine the laboratory blood test
for paraproteinemia, hyperparathyroidism and connective
tissue diseases. A biopsy specimen revealed a thickened
dermis with mucinous change (Figures 2(a) and (b)).
Alcian blue staining at pH 7.0 showed deposits of acid
mucopolysaccharides between the collagen bundles in
Figure 1. Clinical appearance of the nape of the neck at the
first visit.
*Corresponding author.
Copyright © 2012 SciRes. JCDSA
Scleredema Diabeticorum in a Patient with the Normal Range of the Hemoglobin A1c Level
and Impaired Glucose Tolerance
142
Figure 2. (a) and (b) A biopsy specimen from the affected nape
(hematoxylin and eosin stain, original magnification, (a) ×40;
(b) ×100); (c) A specimen stained with alcian blue at pH 7.0
(original magnification, ×100); (d) A specimen stained with
alcian blue at pH 1.5 (original magnification, ×100).
the reticular dermis (Figure 2(c)). Alcian blue staining at
pH 1.5 did not show deposits (Figure 2(d)). A 75 g oral
glucose tolerance test (OGTT) was performed to exam-
ine the serum glucose, serum immunoreactive insulin
(IRI), and serum C-peptide immunoreactivity (CPR)
(Table 1).
We recommended exercising, such as walking, for an
hour per day and eating a nutritionally balanced diet.
Three months later, the induration regressed and flat-
tened (Figure 3). The patient did not wish to undergo an
OGTT after regression.
3. Discussion
Scleredema is caused by deposits of only nonsulfated
acid mucopolysaccharides, which alcian blue stains at pH
7.0 but not at pH 1.5. Scleredema has two main types:
Scleredema adultorum of Buschke and scleredema dia-
beticorum [2]. Buschke-type scleredema is commonly re-
cognized as a post-inflammatory, sudden-onset subtype
that generally regresses within a few weeks to months.
The lack of a recent infectious episode, noted at a first
medical examination, suggests that the eruption was a non-
Buschke-type. Even though the HbA1c level was within
the normal range, we performed an OGTT and identified
impaired glucose tolerance. The eruption was diagnosed
with scleredema diabeticorum associated with impaired
glucose tolerance.
Patients with diabetes mellitus may develop a skin
disorder that is an early indicator of undiagnosed or a
complication of known diabetes mellitus [3]. Cutaneous
signs include scleredema diabeticorum, lichen planus,
acanthosis nigricans, disseminated granuloma annulare,
necrobiosis lipoideca, eruptive xanthomas and others.
Nigam et al. reported that 30.3% patients with lichen
Table 1. Results of 75 g oral glucose tolerance test.
Time (min) 0 30 60 90 120
Serum glucose (mg/dl) 101 147 168 179150
IRI (μU/ ml) 8.1 57.0 44.1 61.857.4
CPR (ng/ ml) 1.37 6.22 6.33 8.219.59
Figure 3. Clinical appearance of the nape of the neck three
months later from the first visit.
planus showed abnormal glucose tolerance [4]. Sclere-
dema diabeticorum is a relatively underestimated com-
plication of diabetes [5,6]. It had been debated whether
scleredema adultorum of Buschke and scleredema dia-
beticorum are identical disease [7], because the condition
of scleredema diabeticorum is believed to be essentially
permanent. Meguerditchian et al. suggested that sclere-
dema of Buschke or scleredema diabetorum is a skin
complication of diabetes and that type 1 or type 2 diabe-
tes may be associated with the condition in more than
50% of cases [6]. Our case would be an instance of scle-
redema diabetorum as a reversible early indicator of dia-
betes.
As shown here, scleredema diabeticorum may be one
of an early indicator of undiagnosed diabetes mellitus.
We hypothesize that regression of scleredema diabeti-
corum in this case may be associated with disappearance
of impaired glucose tolerance as a result of increased
physical activity and a nutritionally balanced diet. Pa-
tients having scleredema on the nape is recommended to
undergo an OGTT even if the HbA1c level is within the
normal range.
REFERENCES
[1] N. Thumpimukvatana, C. Wongpraparut and H. W. Lim,
“Scleredema Diabeticorum Successfully Treated with Ul-
traviolet A1 Phototherapy,” Journal of Dermatolgy, Vol.
37, No. 12, 2010, pp. 1036-1039.
doi:10.1111/j.1346-8138.2010.01014.x
Copyright © 2012 SciRes. JCDSA
Scleredema Diabeticorum in a Patient with the Normal Range of the Hemoglobin A1c Level
and Impaired Glucose Tolerance
Copyright © 2012 SciRes. JCDSA
143
[2] F. Breuckmann, C. Appelhans, A. Harati, S. Rotterdam, P.
Altmeyer and A. Kreuter, “Failure of Low-Dose Meth-
otrexate in the Treatment of Scleredema Diabeticorum in
Seven Cases,” Dermatology, Vol. 211, No. 3, 2005, pp.
299-301. doi:10.1159/000087031
[3] R. S. Gilgor and G. S. Lazarus, “Skin Manifestations of
Diabetes Mellitus,” In: H. Rifkin and P. Raskin, Eds.,
Diabetes Mellitus, Brady Company, Bowie, 1981, pp. 313-
321.
[4] P. K. Nigam, L. Sharma, J. K. Agrawal, G. Singh and S.
K. Khurana, “Glucose Tolerance Studies in Lichen Pla-
nus,” Dermatologica, Vol. 175, No. 6, 1987, pp. 284-289.
doi:10.1159/000248835
[5] M. M. Seyger, F. H. van den Hoogen, S. de Mare, U. van
Haelst and E. M. de Jong, “A Patient with a Severe Scler-
oedema Diabeticorum, Partially Responding to Low-Dose
Methotrexate,” Dermatology, Vol. 198, No. 2, 1999, pp.
177-179. doi:10.1159/000018103
[6] C. Meguerditchian, P. Jacquet, S. Béliard, T. Benderitter,
R. Valéro, F. Carsuzza and B. Vialettes, “Scleredema Adul-
torum of Buschke: An under Recognized Skin Complica-
tion of Diabetes,” Diabetes & Metabolism, Vol. 32, No. 5,
2006, pp. 481-484.
[7] A. Krakowski, J. Covo and C. Berlin, “Diabetic Sclerede-
ma ,” Dermatologica, Vol. 146, No. 3, 1973, pp. 193-198.
doi:10.1159/000251956