A brief touch on some of the skin manifestations associated with diabetes mellitus




Diabetes mellitus is a disorder occurring when the body is unable to process glucose resulting in high blood glucose. It is a very common disease; it has been estimated that around 18% of the adult population in Saudi Arabia suffer from diabetes mellitus. There are 3 types of diabetes mellitus, type 1, type 2, and gestational. Type 1 occurs due to autoimmune destruction of insulin-producing pancreatic beta cells causing little to no insulin to be released. On the other hand, type 2 is due to insulin resistance rather than destruction of insulin-producing cells.



There are a couple of skin manifestations occurring in diabetics, and they are usually more common in type 2 than type 1. Furthermore, poorly controlled diabetes mellitus is associated with an increased incidence of skin infections and “diabetic foot”. Acanthosis nigricans (AN) associated with diabetes mellitus (benign AN) has an insidious onset and often described as velvety thickening and hyperpigmentation of the skin. Another disorder often associated with diabetes mellitus is Necrobiosis lipoidica (NL). NL lesions start as a papule that slowly develops into a well-demarcated plaque. A combination of peripheral arterial disease and peripheral neuropathy causes something known as “diabetic foot”. Patients suffering from diabetic foot have reduced sensation in their extremities, thus making them more prone to acquire undiscovered minor injuries that may later progress to full-thickness ulcers.



Diabetes mellitus is linked with some skin manifestations, we have briefly touched on a few of them such as acanthosis nigricans, necrobiosis lipoidica, and diabetic foot. Maintaining proper blood glucose and frequent foot care is important in the prevention of ulcers in the foot and infections.




Written by: Khalid Al Dakheel, Medical Student 



Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, Seventh Edition



Viral warts




Viral warts are ubiquitous and harmless skin growths caused by human papillomavirus (HPV). It infects epidermal or mucosal cells creating a warty knoll lesion called verruca.


Diagnosis is clear-cut and based on clinical grounds, but in some cases uncertainty emerges. Facial warts can be mistaken for lichen nitidus, in such instances, histological differences confirm the diagnosis.


Common locations for warts include the hands and feet, but they manifest differently depending on the location. Palmar or hand warts appear as hyperkeratotic papules, whereas plantar or feet warts are exhibited as thick plaques. Both arise under pressure points and may cause pain.


Treatments are discounted due to the nature of warts; they resolve spontaneously and appear to be for the most part asymptomatic. If treatment is pursued, different modalities can be used to tackle it. The use of topical salicylic acid treatment, which is typically tolerated, works gently at exfoliating the skin from the epidermal layer, softening the skin, and encouraging cell turnover. Another modality, which the commonest, utilizes liquid nitrogen, formerly called “cryotherapy”, to directly destroy and induce secondary inflammation.


In general, cutaneous viral warts are uncommon, nonetheless, they do appear often in children, particularly schoolchildren and immunocompromised. Patients choose to excise warts for cosmetic reasons, pain, or discomfort, but they do not pose a health threat as they are benign, however, they are mischievously contagious and can be spread through contact.




Written by: Naif Alshaikh, Medical Student 






Cutaneous Melanoma



Cutaneous melanoma is a malignant neoplasm of the melanocytes. Melanocytes are cells found in the basal layer of the epidermis which its main function is to produce the pigment melanin that is responsible for skin color. As one of the three major types of skin cancer (basal cell carcinoma and squamous cell carcinoma being the other two) melanoma remains the deadliest, causing the vast majority of the skin cancer-related deaths although it only accounts for approximately 5% of the skin cancer cases.


There are four major forms of melanoma being: superficial spreading, nodular, lentigo maligna, and acral lentiginous melanomas. superficial spreading form remains the most common and accounts for about 70% of melanomas. Studies have shown that the major risk factor for melanoma development is exposure to Ultraviolet (UV) radiation as UV radiation frequently leads to DNA mutations. Another risk factor is the melanocytic nevus (colloquially known as mole or birthmark) nevi are benign lesions composed of clusters of melanocytes. This leads to a dark pigmented spot on the skin due to the large amount of melanin production.


Clinicians assess lesions based on the “ABCDE rule” that is meant to indicate A: asymmetry, B: irregular border, C: color variations, D: diameter >6 mm, and E: elevated surface in order to diagnose malignant melanoma.



Written by: Bayan Alhazmi, Medical Student 





Hidradenitis Suppurativa: Causes, clinical features, and management



Hidradenitis Suppurativa (HS) is a chronic inflammatory skin disease affecting the apocrine gland causing suppurative lumps in areas of skin folds, such as the axilla and groin. HS tends to appear around puberty and is three times more common in females. The exact cause is unknown; however, some predisposing factors include obesity, smoking, and genetic predisposition to acne.



Severity and progression of HS differs, some patients may only experience mild symptoms and thus do not seek treatment. On the other hand, they may undergo severe progression with chronic pain, draining sinuses, scarring and significant psychological impact. Treatment includes glucocorticoids, antibiotics, and surgery. In addition, isotretinoin could be used in early presentations to prevent follicular plugging.



HS is a chronic skin disease causing recurrent, deep, and painful abscesses. In severe cases it has a substantial psychological effect, thus every effort should be made to improve the patient’s quality of life.





Written by: Khalid Al Dakheel, Medical Student 



Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, Seventh Edition



Lichen Planus: a brief summary.




Lichen Planus is a chronic disorder that can present with a variety of dermatological manifestations. There are many clinical types of Lichen Planus which are based on the extent of involvement of different body parts, examples include Cutaneous, Mucosal and Nail Lichen Planus.


It is thought to be of an autoimmune etiology where the immune system attacks a protein within the skin and mucosal surfaces. Risk factors that may be involved include genetic predisposition, injury to the skin (Koebner’s Phenomenon) and skin diseases such as Herpes Zoster. Some drugs can induce a Lichenoid rash, examples include Quinine and Captopril.


Skin manifestations of Lichen Planus usually are in the form of papules and plaques. The plaques are crossed by fine white lines called Wickham’s striae. Lichen planus can occur anywhere on the skin but common sites include the wrists, ankles and the lower back. The plaques usually resolve after many months.


The diagnosis of Lichen Planus is usually clinical. In cases of diagnostic uncertainty, a skin biopsy may be needed to rule out competing diagnoses.


Mild Lichen Planus is usually treated with topical medications like steroids, calcineurin inhibitors and retinoids. More severe local disease, or in widely distributed disease, oral steroids are needed. Other immuno-modulators may be combined with oral steroids to reduce the dose, examples include Methotrexate and Azathioprine.



Written by: Turki Alsehli, Medical Student 





Microneedling: a new approach in dermatology



Microneedling (percutaneous collagen induction therapy) is a new promising mini-invasive therapeutic procedure where small holes are created across the stratum corneum while keeping the epidermis partially intact.


The method is called microtraumatization which leads to an activation of the healing cascade and growth factors, which in turn activate cell proliferation in the wound and increase the synthesis/deposition of collagen (elastin complex with successive transformation of collagen III to collagen I) and neoangiogenesis which ultimately accelerates scar remodeling with minimal damage to the epidermis. This produces microchannels that increase skin permeability which greatly increases the efficacy of topical treatments applied after the procedure. Microneedling has been widely used for the treatment of skin alterations of different etiologies, like burns, acne scars, and other textural skin anomalies.


Numerous studies are currently examining its potential in focal diseases of inflammation, dyschromia, and photodamage. In the meantime, many clinical experiences show that microneedling appears to be a suitable micro-invasive treatment for the improvement of scar quality which has less risk of infection, post-inflammatory hyperpigmentation, and scarring compared to other resurfacing modalities.




Written by: Bayan Alhazmi, Medical Student 








What is Rosacea? Causes, clinical features and treatment



Rosacea is a common condition and one that dermatologists come across all the time. It is characterized by either transient or persistent facial erythema involving a chronic rash, sometimes accompanied with conspicuous blood vessels and protruding lesions.


Although the cause is still unclear, several hypotheses have suggested a multifactorial etiology, whether it be genetic, environmental or chronic prolonged exposure to ultraviolet radiation.


Rosacea is subdivided into four stages: First stage consists of episodes of flushing often frequent, followed by the second stage which comprise persistent erythema and dilated vessels (telangiectases). A minority develop the third stage, mainly manifested as papules and pustules. The fourth and last stage is Rhinophyma, a skin deformity appearing as large, bumpy red nose. It is seen more in men than in women.


Diagnosis is based on diagnostic phenotype, and it usually does not require an invasive investigation. Sometimes skin biopsies are performed to confirm diagnosis.


There is no available treatment that provides desirable results for the redness. Precautionary and preventive measures, prescribing sunscreen and avoiding exposure to heat. Oral antibiotic treatment is available, but its side-effect in the long run outweigh the calming effect. Topical treatment are as effective as oral, azelaic acid cream is efficacious at treating mild forms of rosacea.


Addressing Rosacea is a tricky task; the pathophysiology is still not fully understood and more research is needed to be able to target rosacea at the root cause. For the time being, lifestyle changes such as wearing sunscreen and avoiding excessive cold or heat have profound impact on the severity of the disease.


Written by: Naif Alshaikh, Medical Student 



DermaNet NZ
The Journal of Investigative Dermatology

Rebora, Alfredo. “Rosacea.” Journal of investigative dermatology 88.s 3 (1987): 56-60

Association of Psoriasis with the Risk for Obesity and Type 2 Diabetes Mellitus




Psoriasis is a chronic immune-mediated inflammatory skin disease characterized by uncontrolled proliferation of keratinocytes, release of proinflammatory cytokines, and recruitment of T cells to the skin that causes skin cells to multiply up to 10 times faster than normal which create red patches covered with white scales. these patches can grow anywhere, but mostly on the scalp, elbows, and knees.

Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of heart diseases and type 2 diabetes mellitus characterized by abdominal obesity, insulin resistance, dyslipidemia, and elevated blood pressure.

Like in psoriasis, systemic inflammation also occurs in patients with metabolic syndrome, and levels of a number of inflammatory markers, such as Tumor Necrosis Factor, are elevated in both diseases. This made researchers question if there is a common etiology.

A cross-sectional, population-based twin study published by JAMA Dermatology, included 34 781 Danish twins, 20 to 71 years of age. Revealed a link between psoriasis and metabolic syndrome, in particular, obesity and type 2 diabetes mellitus, this connection is rather important as those two comorbidities can lead to increased mortality, especially due to cardiovascular diseases.

The study found that obesity is about twice as prevalent in patients with psoriasis compared with the general population. The same results have been obtained for type 2 diabetes mellitus.

Several factors might explain the association between psoriasis and the metabolic syndrome, notably genetics and environmental exposures (such as tobacco smoking, alcohol consumption…etc.). The twin design shows the relative contribution of genetic and environmental factors to a given disease which is necessary for this area of research.

The results support that Psoriasis, type 2 diabetes mellitus, and obesity are strongly associated with adults after taking key confounding factors (sex, age, and smoking …etc.) into account which indicates a common genetic etiology of psoriasis and obesity.

Conducting future studies on specific genes and epigenetic factors will unravel the direct correlation between those 3 disorders.




Written by: Bayan Alhazmi, Medical Student 








Vitiligo: causes, clinical features, diagnosis and general management



Vitiligo is an acquired disorder of the skin characterized by well-circumscribed macules or patches of depigmentation. Vitiligo can be cosmetically disabling, especially in people of darker skin. It is caused by destruction of melanocytes in the skin, which are essential for the production of melanin. The etiology is thought to be due to an autoimmune process, triggered in people with certain genetic susceptibilities.  

Vitiligo can affect any part of the body, common sites are sun-exposed areas (face, neck and hands) and skin folds (armpits, groin). Vitiligo may appear following trauma to the skin, this is known as Koebner’s phenomenon. The pattern of depigmentation in Vitiligo is variable. It may affect a single patch of skin or it may involve multiple areas distributed throughout the body. Vitiligo lesions usually extend for a few months before stabilizing for variable periods. This cycle of pigment loss followed by stability of lesions may continue for years.

Vitiligo may be classified as segmental or non-segmental. In segmental vitiligo, there is usually a single patch of depigmented skin. This type also more commonly affects younger people and is more likely to be stable after the initial period of extension. Non-segmental vitiligo is characterized by lesions that are bilateral and symmetrical. Each of these types (Segmental and non-segmental) includes many other subtypes which are based on the distribution of lesions.

Vitiligo is typically a clinical diagnosis. Depigmented lesions are readily seen on Wood’s lamp examination. At times of diagnostic difficulty, a skin biopsy may be needed to rule out other possible causes of depigmentation. Blood tests such as thyroid function markers and Vitamin B12 levels may be ordered to check for possible co-existing autoimmune disorders.

General measures for the management of Vitiligo include preventing skin injury and wearing sunscreen. Specific treatment for Vitiligo may include topical medications such as steroids or Calcineurin inhibitors. Phototherapy is another option which aims at achieving re-pigmentation of the involved area. Systemic therapies for Vitiligo are available, examples include oral steroids, Methotrexate, and Cyclosporin. These all have immune-modulating properties and target the possible etiology of the disease. JAK2 inhibitors such as Ruxolitinib are currently being investigated for the treatment of Vitiligo and may be used in the future as a second-line medication. Depigmentation therapy may be an option for severely affected patients in whom other methods of treatment are not effective.



Written by: Turki Alsehli, Medical Student 





Front Immunol. 2019 Dec 3;10:2847. doi: 10.3389/fimmu.2019.02847. eCollection 2019.

Emerging Topical and Systemic JAK Inhibitors in Dermatology. Solimani F, Meier K, Ghoreschi K.

The elusive connection between vitamin D and skin health



Vitamin D is a fat-soluble vitamin that has an imperative role in health. It regulates calcium metabolism and homeostasis, but its scope of function extends beyond that, particularly the skin.


The production of vitamin D occurs in the skin in response to ultraviolet B radiation from sunlight. Once it is synthesized, it exerts an immunomodulatory effect on immune cells by dampening overactive signaling cells from secreting inflammatory mediators, in addition, vitamin D aids in the defense against opportunistic infections of the skin by upregulating antimicrobial gene expression, which collectively consolidates and maintains the integrity of the cutaneous barrier.


A myriad of studies in the literature have highlighted vitamin D’s potential therapeutic properties for a number of dermatological diseases, namely psoriasis, atopic dermatitis, vitiligo and many other skin maladies. One study elucidated that oral vitamin D conferred to an improvement of psoriasis in 88% of the patients. Another meta-analysis study demonstrated that the risk of vitiligo is inversely associated with vitamin D serum.


There are many sources in which you can ascertain vitamin D. Exposure to sunlight is remarkably efficient at converting vitamin D into its active form, followed by dietary supplementation, with negligible amount present in dietary intake, mostly in commercialized processed foods which has been fortified with essential compounds.


With a growing body of research on this matter and promising results, vitamin D has proven to be a quintessential vitamin for the skin. Insufficient levels are therefore associated with multiple dermatological disorders, and adequate sunlight exposure and supplementation with regular blood tests for vitamin D serum level are advisable for healthy skin.



Written by: Naif Alshaikh, Medical Student 


Bergqvist C, Ezzedine K. Vitamin D and the skin: what should a dermatologist know? G Ital Dermatol Venereol 2019;154:669-80. DOI: 10.23736/S0392-0488.19.06433-2


Wadhwa B, Relhan V, Goel K, Kochhar AM, Garg VK. Vitamin D and skin diseases: A review. Indian J Dermatol Venereol Leprol 2015;81:344-55


Perez A, Raab R, Chen TC, Turner A, Holick MF. Safety and efficacy of oral calcitriol (1,25-dihydroxyvitamin D3) for the treatment of psoriasis. Br J Dermatol 1996;134:1070–8.

COVID-19: how is it related to the skin?

In December 2019 unexplained pneumonia cases started arising in Wuhan, China due to a new pathogen called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and thus the disease was named Coronavirus Disease 2019 (COVID-19). Cases started spreading rapidly around the globe and on March 12th World Health Organization (WHO) declared it as a pandemic. Some of the clinical signs associated with it are fever, fatigue and dry cough. In addition to presenting symptoms and signs, nasopharyngeal and oropharyngeal swab can aid in diagnosis.


There are very limited data in literature about the cutaneous manifestation of COVID-19 so far, however, data collected from 88 patients in Lecco, Italy in which 14 of them presented with skin rash mostly affecting the trunk region. In addition, three patients presented with urticaria and one patient had chickenpox-like vesicles. It was concluded that the skin symptoms observed in COVID-19 were frequently seen in common viral infections. Furthermore, the severity of the skin symptoms did not seem to correlate with the severity of the disease. Due to additional infection prevention steps taken by first-line healthcare workers, 97% of them reported having skin damages, some of which are dryness and desquamation. Sites involved were mainly the nasal bridge, hands, cheek, and forehead. Therefore, preventive measures must be taken which include emollients, barrier creams, and moisturizers especially before applying personal protective equipment. Further steps should be taken to maintain hand hygiene and moisturization such as using unscented soap and avoiding using too much. Additionally, washing hands with warm water instead of hot water and applying moisturizers immediately after drying hands.


In conclusion, further studies should be done on the specific skin symptoms associated with COVID-19 infection. Skin damage and dryness are common conditions, especially with frequent hand washing during the pandemic, therefore, additional measures need to be taken to prevent such conditions.


Written by: Khalid Al Dakheel, Medical Student @ KSU








The unexpected correlation between BMI index and acne vulgaris


It’s common knowledge that a healthy diet can improve skin condition greatly
as there are many products and food supplements that claim to refresh and
nourish the skin while preventing acne, but exactly how much can a conscious
diet affect our skin?

The most common form of acne is Acne Vulgaris which is “a chronic
inflammatory skin disease of pilosebaceous unit“ that many Adolescents
suffer from and deal with on a daily basis which is detrimental to their
mental and psychological health.

Many studies conducted in the last decade show a notable correlation
between different dietary factors (like dairy consumption and high glycemic
load diet) and acne vulgaris as they are thought to increase sebum
production which leads to blocking hair follicles hence causing acne and

In 2019 a new article published by The Journal of The American Academy of
Dermatology proposed a new idea into the table, that the BMI index level may
have an association with the risk of developing Acne Vulgaris.

The results suggest that in Youths, high BMI index and Obesity are “inversely
associated with acne in a dose-dependent manner” which is odd as a high
calorie diet doesn’t necessarily reflect a healthy nor desirable approach to
reduce acne vulgaris risk but is surely interesting.

The connection between acne vulgaris and the BMI index remains unclear
which provides space for future research to improve the current


Written by: Bayan Alhazmi, Medical Student @ KSU