s

cleredema Diabeticorum: A Common and

Distinct Cutaneous Manifestation of
Diabetes Mellitus
GARY W. COLE, JOHN HEADLEY, AND RONALD SKOWSKY

Scleredema diabeticorum is characterized by a dramatic increase in the thickness of the skin of the
posterior neck and upper back. Of the 17 scleredema patients diagnosed by us in the last 15 yr, 16
have had type II diabetes mellitus. In a prospective study of 484 diabetic outpatients we found the
prevalence of scleredema to be 2.5%. Angina pectoris was the only complication that occurred significantly more frequently in scleredematous diabetic patients than in a control group of diabetic patients
without scleredema. Scleredema diabeticorum is a distinct cutaneous condition peculiar to diabetic
individuals and ought not to be confused with scleredema of Buschke or scleroderma. DIABETES CARE 6:
189-192, MARCH-APRIL 1983.

here are a large number of cutaneous abnormalities

that have been frequently noted in patients with
diabetes mellitus. The skin lesions most specifically associated with diabetes are necrobiosis lipoidica and diabetic dermopathy.'
A less well-known but rather dramatic cutaneous marker
of diabetes mellitus is scleredema. The scleredema of diabetes
is characterized by a remarkable thickening of the dermis of
the neck and upper back which, although essentially permanent, causes little morbidity. ' In this study we report the
results of our investigation of the prevalence of scleredema
in diabetic patients as well as its clinical implications in the
prognosis of diabetes mellitus.

domly selected diabetic patients from the same clinic population with reference to important prognostic factors in diabetes mellitus. These factors included retinopathy (defined
as the presence of retinal hemorrhages, exudates, or vascular
proliferation); peripheral vascular disease (defined as a history
of ischemic ulceration, gangrene, peripheral arterial bypass
grafts, or a significant decrease in pulse pressure); nephropathy (defined by the presence of proteinuria greater than
145/95); and neuropathy (defined as a deficit in autonomic,
sensory, or motor function referable to diabetes). Statistical
analysis of the prevalence of diabetic complications was performed according to the method of Swinscow using an adaption of the Student t test.4

MATERIALS AND METHODS

Initially, a retrospective review of all scleredema patients

seen at the University of California, Irvine, Affiliated Dermatology Clinics within the last 15 yr was conducted. The
vast majority of these patients have been seen and diagnosed
by the authors within the last 4 yr at the Veterans Administration Medical Center, Long Beach, California. Skin biopsies were performed on most patients and processed using the
standard hematoxylin and eosin stain. Occasionally special
stains for mucopolysaccharides were done.
In a prospective study all patients reporting to Diabetes
Clinic at the Veterans Administration Medical Center, Long
Beach, over a 6-mo period were examined for the presence
of scleredema. The records of 12 scleredema patients culled
from this clinic were compared with the records of 100 ran-

RESULTS

Since 1968 we have documented scleredema in 17 patients.

Fifteen new cases were discovered within the last 4 yr at the
Veterans Hospital, Long Beach. Ninety-four percent of these
patients had type II diabetes and most required medication
for control of their blood sugar.
Individuals with scleredema were virtually asymptomatic
and few of them, therefore, were able to accurately date the
onset of their disease. In those patients who could date the
onset, the duration was prolonged (3-30 yr). In the 4 yr that
many of these patients have been followed, the scleredematous involvement has remained unchanged.
In all our patients the signs of scleredema were similar.
The skin of the neck and upper back was always involved

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SCLEREDEMA DIABETICORUM/G. W. COLE, J. HEADLEY, AND R. SKOWSKY

FIG. I Patient with scleredema and diabetes

meUitus. The red area in the center of the back
was indurated and leathery.

with occasional extension to the deltoid and lumbar regions

(Figure 1). The scleredematous involvement in these areas
was characterized by an impressive thickening of the dermis,
which produced a peau d'orange appearance. This thickening
"pitted" under constant forceful thumb pressure for 30 s. Most
patients appeared to have decreased cutaneous sensation to
pain and light touch in affected areas. Occasional patients
had a decreased range of motion of the upper extremity if
the deltoid skin was involved. Affected areas had a modest
erythematous tinge.
Pathologic examination obtained from scleredema patients
was carried out on tissues by punch biopsy. The interpretation
of such material is difficult because the major criteria for the
diagnosis of this condition is an increase in dermal thickness.
This thickening is due to an increase in collagen or mucin
content (Figure 2), but neither of these findings is specific
for scleredema. Specimens were therefore interpreted as
"consistent with scleredema" by our pathology service.
We prospectively studied the prevalence of scleredema in
an unselected group of outpatients reporting to the diabetic
clinic at the Veterans Administration Medical Center, Long
190

Beach. Of 484 patients examined, 12 were found to have

scleredema resulting in a prevalence rate of 2.5%.
We selected a number of clinical factors likely to be important in the morbidity and mortality of diabetic patients.
We determined the prevalences of these complications in 12
scleredema patients discovered in diabetes clinic and compared these with prevalences found in a group of 100 ageand sex-matched diabetic controls (Table 1). The average
age of our scleredematous diabetic group was 56.4 yr compared with 54.6 yr for our control diabetic group. The average
duration of diabetes in our scleredema group was 14.2 yr
compared with 12 yr for controls. Seventy-five percent of
scleredematous diabetic subjects required insulin compared
with 70% of control diabetic subjects. Scleredematous diabetic patients were, on the average, 71.5 pounds overweight
compared with 31.2 pounds for our unaffected diabetic group
(Metropolitan Life Insurance Company, New York). Angina
was the only statistically significant factor in which the groups
differed. Our diabetic scleredema patients had more than
twice the prevalence of angina found in nonscleredematous
diabetic patients. Although scleredema patients had less ar-

DIABETES CARE, VOL. 6 NO. 2, MARCH-APRIL 1983

SCLEREDEMA D1ABETIC0RUM/G. W. COLE, J. HEADLEY, AND R. SKOWSKY

FIG. 2 The histologic appearance of scleredema

is characterized by a relative increase in fibrous
tissue in the dermis. A colloidal iron stain was
positive for mucopolysaccharides (hematoxylin and
eosin, X 40).

teriosclerotic vascular disease than did the diabetic controls,

this difference was not statistically significant.
DISCUSSION

Some 30% of diabetic patients have some sort of cutaneous

involvement during their disease.5 Of the skin changes seen
in diabetic individuals, most are either nonspecific or noted
as part of the systemic response to diabetes.2 Only two dermatologic lesions, necrobiosis lipoidica diabeticorum (NLD)
and diabetic dermopathy (DD), are thought to be highly
specific for diabetes. NLD has the clinical appearance of
orange-red telangiectatic plaques on the anterior lower leg,
TABLE 1
Frequency of complications in diabetic patients
( + ) Scleredema
(N = 12)

() Scleredema
(N = 100)

Complication

(%)

(%)

Retinopathy
Cataracts
Peripheral vascular disease
Cerebrovascular accidents
Angina pectoris
Myocardial infarction
Nephropathy
Neuropathy
Hypertension

25
17
8
8
67
17
0
42
67

35

*P<0.05.

20
21
10
28*
21
12
38
49

often accompanied by ulceration. The prevalence of NLD

has been found to be 0.1-0.3% among diabetic individuals
(types I and II), and 35% of patients with NLD do not have
carbohydrate intolerance.6 DD was noted in as many as 60%
of diabetic patients but was also noted in 20% of patients
with other endocrine conditions and in 1.5% of normal medical students.7 This condition also occurs on the anterior
lower legs and is characterized by multiple hyperpigmented
depressed scars.
We found the prevalence of scleredema diabeticorum to
be 2.5% in diabetic patients (type II). Ninety-four percent
of our patients with scleredema had diabetes mellitus. Scleredema diabeticorum is, therefore, more prevalent in type II
diabetic patients than NLD, and is associated with diabetes
more frequently than is DD. Because most of our patients
were seen in a Veterans Medical Center, the majority of our
patients were male and middle-aged. It is possible that scleredema diabeticorum could occur more frequently in this group
than in a group of diabetic individuals more representative
of the whole population.
Part of the difficulty of recognizing the specific relationship
between scleredema and diabetes has been the confusion
between the scleredema seen in diabetic individuals and the
scleredema of Buschke.8 Buschke's scleredema is a rare disorder in which areas of dermal thickening occur, frequently
after an upper respiratory infection, and spontaneously clear
in months or years.9 The face is frequently involved as well
as arms and hands. Females are more frequently affected than
males and 29% of the cases occur in childhood. Scleredema
diabeticorum occurs almost exclusively in patients with long-

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SCLEREDEMA DIABETICORUM/G. W. COLE, J. HEADLEY, AND R. SKOWSKY

standing diabetes mellitus, is essentially permanent, has no

relationship to infection, always occurs on the posterior neck
and upper back, and has not been reported in children.
Scleredema diabeticorum causes little morbidity in affected
patients and there is no effective treatment.
The diagnosis of diabetic scleredema is easily made. The
dramatic increase in dermal thickness is obvious by simply
palpating the involved skin. Ultrasound imaging may be used
to quantify this increase in thickness.10 It is difficult to make
an unequivocal diagnosis of scleredema from the histologic
examination of a skin biopsy specimen alone, since dermal
thickness is difficult to evaluate unless an attempt is made
to secure a full thickness excisional biopsy. Early lesions of
scleredema are thought to have an excess of mucopolysaccharide, but older lesions apparently lack this change.11 Although scleroderma occasionally may be confused with scleredema, the lack of systemic involvement in scleredema is
usually sufficient to distinguish it.12
Rosenbloom et al.13 recently reported a group of children
with type I diabetes mellitus, decreased joint mobility, and
increased microvascular complications. These patients had
"waxy skin" confined to the dorsal surface of their hands
apparently related to an increase in dermal thickness. Although our scleredema patients had no special risk of microvascular complications, an increase in dermal thickness occurred in both pathologic states. One could speculate that
defective collagen biosynthesis or metabolism may affect the
collagenous component of the basement membrane in diabetic individuals.
There seems little doubt that scleredema of the type our
patients exhibited is a specific manifestation of diabetes mellitus in the skin. If one can accept the latinized adjective
"diabeticorum" to describe necrobiosis lipoidica, we can see
little objection to the use of the term, scleredema diabeticorum, to label the skin disease herein described.
From the Dermatology Service and Endocrinology Section, Veterans Administration Medical Center, Long Beach, California, and

192

the Department of Dermatology, University of California, Irvine,

California.
Address reprint requests to Gary W. Cole, M.D., 5901 E. 7th
Street, Long Beach, California 90822.

REFERENCES
1
Hanson, T.: Diabetic dermopathy. In Clinical Dermatology.
Demis, D. J., Dobson, R. L., and McGuire, J., Eds. Hagerstown,
Harper and Row, 1979:4-10.
2
Fleischmajer, R., Faludi, G., and Krol, S.: Scleredema and
diabetes mellitus. Arch. Dermatol. 1970; 101:21-35.
3
Cohn, B. A., Wheeler, C. E., and Briggaman, R. A.: Scleredema adultorum of Buschke and diabetes mellitus. Arch. Dermatol. 1970; 101:27-35.
4
Swinscow, T. D. V.: Statistics at Square One. London, British
Medical Association, 1980:28-29.
5
Allen, G. E.: Diabetes mellitus and the skin. Practitioner 1969;
203:189-93.
6
Mueller, S. A., and Winkelmann, R. K.: Necrobiosis lipoidica
diabeticorum. A clinical and pathologic study of 171 cases. Arch.
Dermatol. 1966; 93:272-81.
7
Danowski, T. S., Sabeh, G., Sarver, M. E., Shelkrot, J., and
Fisher, E. R.: Shin spots and diabetes mellitus. Am. J. Med. Sci.
1966; 251:570-75.
8
Curtis, A. C , andShulak, B. M.: Scleredema adultorum. Arch.
Dermatol. 1965; 92:526-42.
9
Rook, A., Wilkinson, D. S., and Ebling, F. S. G.: Textbook
of Dermatology, 3rd edit. Oxford, Blackwell, 1979.
10
Cole, G. W , Handler, S. J., and Burnett, K.: The ultrasonic
evaluation of skin thickness in scleredema. J. Clin. Ultrasound.
1981; 9:501-503.
11
Lever, W. F., and Schaumburg-Lever, G.: Histopathology of
the Skin, 5th edit. Philadelphia, Lippincott, 1975.
12
Joblonska, S.: Scleroderma and Pseudoscleroderma, 2nd edit.
Warsaw, Polish Medical Publ., 1975.
13
Rosenbloom, A. L , Silverstein, J. H., Lezotte, D. C , Richardson, K., and McCullum, M.: Limited joint mobility in childhood
diabetes mellitus indicates increased risk for microvascular disease.
N. Engl. J. Med. 1981; 305:191-94.

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