SEMINARS IN THROMBOSIS AND HEMOSTASIS—VOLUME 17, NO. 4, 1991
Diabetic Capillary Angiopathy of the Dermis of the Hand and Foot in Patients with Diabetes Mellitus PANAGIOTIS BALAS, M.D.
From the First Department of Surgery, Athens University Medical School, Athens, Greece. Reprint requests: Dr. Balas, First Department of Surgery, Athens University Medical School, Athens, Greece. 448
OBSERVATION ON CAPILLARY CHANGES IN THE HANDS AND FEET OF DIABETICS In our vascular laboratory the last 8 years vital capillaroscopy was applied in many hundreds of patients with peripheral arterial occlusive disease, mainly of atherosclerotic origin, and various degrees of capillary destruction were found, depending mainly on the severity of ischemia. These changes were classified according to Fagrell's classification. To our surprise we have also found very advanced morphologic changes and destruction of the capillaries on the feet, especially of the toes, as in ischemic conditions of diabetic patients of both sexes, which were free, at least clinically, of peripheral atherosclerotic occlusive disease, namely, without ischemic symptoms, existence of normal peripheral pulses, and normal ankle-brachial blood pressure index with Doppler ultrasound. Also, similar capillary changes were found in the fingers of diabetics without ischemia but with normal ultrasonic digital arterial tracings. We have recently started using capi-flow techniques in vital capillaroscopy with a special computer program for the study not only of the characteristics of the morphology of the capillaries, such as the diameter, but also the capillary flow velocity. With these new techniques, we expect to elicit more information on the morphologic and functional changes in the capillaries of the dermis of diabetic patients. We have set-up in our vascular laboratory a protocol to correlate this diabetic capillary angiopathy to various factors, such as sex, age, duration, severity, and insulin dependence of the diabetic. We are also trying to identify various factors that might reverse this microangiopathy and at what stage. Bollinger et al4 and Fagrell5 have made similar observations to ours. These two investigators are the pioneers of the reintroduction of the application of capillaroscopy of the hands and feet in patients with
Copyright © 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: University of British Columbia. Copyrighted material.
Retinal and renal microangiopathy have been wellknown complications of diabetes mellitus for many decades. By using electron microscopy, capillary ultrastructural thickening of the capillary basement membrane was found in muscles, nerves, and other organs. However, the existence of angiopathy at the capillary level of the skin of the hands and feet of the diabetic patients is still controversial.1,2 It has been shown that atherosclerotic processes demonstrate some characteristic features in the diabetic patient. They are more common in diabetics, and appear at a younger age, advance more rapidly, and are almost as common in women as in men. The atherosclerotic changes are quantitatively greater in diabetics than in nondiabetics and present a pattern of more distal arterial distribution in the arteries below the knee, as far as the plantar and arteries of the toes. This distal atherosclerotic distribution has been referred to as the disease of the small arteries in diabetics and is considered by most angiologists and vascular surgeons to be one of the main causes, together with peripheral neuropathy, of the development of the diabetic foot.3 A few years ago, LoGerfo and Coffman,1 in a lead article in the New England Journal of Medicine, challenged not only the existence of microangiopathy in the diabetic foot but also suggested that this term should be abandoned and any reference to that would be misleading and faulty.
CAPILLARY ANGIOPATHY—BALAS
DISCUSSION On the basis of the findings of Bollinger et al4 and Fagrell5 together with our observations, there is no doubt about the existence of microangiopathy, at the capillary level, in the dermis of the hands and feet of diabetic patients without the coexistence of ischemia. This condition could be coined diabetic capillary angiopathy of the dermis. The mechanism for the development of this microangiopathy is unknown. Possible vasomotor disturbances due to sympathetic neuropathy or hemorrheologic changes together with hormonal action might play a pathogenetic role. We suspect that this microangiopathy is probably responsible, at least in part, for the complications of the diabetic foot, mainly infection, but we cannot offer at present any evidence of such a pathogenetic mechanism.
CONCLUSIONS Diabetic capillary angiopathy, due to capillary changes of the dermis of the hands and feet in diabetics is an actual pathologic condition. The mechanism for its development is unknown. Efforts have to be made to clarify the pathogenetic mechanism of this microangiopathy and its role in the development and complications of the diabetic foot. Pharmacologic and other factors must be tried for reversibility of diabetic capillary changes.
REFERENCES 1. LoGerfo FW, JD Coffman: Vascular and microvascular disease of the foot in diabetes. N Engl J Med 311:1615-1619, 1984. 2. LoGerfo FW: Vascular disease, matrix abnormalities, and neuropathy. Implications for limb salvage in diabetes mellitus. J Vasc Surg 5:793-796, 1987. 3. Levin ME, LW O'Neal: The Diabetic Foot. C. V. Mosby St. Louis, 1988. 4. Bollinger A, J Frey, K Jager, K Franzeck: Diffusion through skin capillaries in patients with long-term diabetes, scleroderma and chronic venous incompetence. Int Angio 2:159-165, 1983. 5. Fagrell B: Monitoring the effects of vasoactive drugs by capillaroscopy and capillary blood flow velocity. Int Angio 2:153-158, 1983. 6. Franzeck UK, G Isenring, J Frey, A Bollinger: Video-densitometric pattern recognition of Na-fluorescein diffusion in nailfold capillary areas of patients with acrocyanosis, primary vasospastic and secondary Raynaud's phenomenon. Int Angio 2:143-152, 1983.
Downloaded by: University of British Columbia. Copyrighted material.
peripheral vascular diseases, during the last 10 or more years. Bollinger et al, by using a special technique with fluoroscein, the so-called fluoroscein microangiopathy, were able to demonstrate characteristic changes of the capillaries in diabetics.6
449
Diabetic Capillary Angiopathy of the Dermis of the Hand and Foot in Patients with Diabetes Mellitus PANAGIOTIS BALAS, M.D.
From the First Department of Surgery, Athens University Medical School, Athens, Greece. Reprint requests: Dr. Balas, First Department of Surgery, Athens University Medical School, Athens, Greece. 448
OBSERVATION ON CAPILLARY CHANGES IN THE HANDS AND FEET OF DIABETICS In our vascular laboratory the last 8 years vital capillaroscopy was applied in many hundreds of patients with peripheral arterial occlusive disease, mainly of atherosclerotic origin, and various degrees of capillary destruction were found, depending mainly on the severity of ischemia. These changes were classified according to Fagrell's classification. To our surprise we have also found very advanced morphologic changes and destruction of the capillaries on the feet, especially of the toes, as in ischemic conditions of diabetic patients of both sexes, which were free, at least clinically, of peripheral atherosclerotic occlusive disease, namely, without ischemic symptoms, existence of normal peripheral pulses, and normal ankle-brachial blood pressure index with Doppler ultrasound. Also, similar capillary changes were found in the fingers of diabetics without ischemia but with normal ultrasonic digital arterial tracings. We have recently started using capi-flow techniques in vital capillaroscopy with a special computer program for the study not only of the characteristics of the morphology of the capillaries, such as the diameter, but also the capillary flow velocity. With these new techniques, we expect to elicit more information on the morphologic and functional changes in the capillaries of the dermis of diabetic patients. We have set-up in our vascular laboratory a protocol to correlate this diabetic capillary angiopathy to various factors, such as sex, age, duration, severity, and insulin dependence of the diabetic. We are also trying to identify various factors that might reverse this microangiopathy and at what stage. Bollinger et al4 and Fagrell5 have made similar observations to ours. These two investigators are the pioneers of the reintroduction of the application of capillaroscopy of the hands and feet in patients with
Copyright © 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: University of British Columbia. Copyrighted material.
Retinal and renal microangiopathy have been wellknown complications of diabetes mellitus for many decades. By using electron microscopy, capillary ultrastructural thickening of the capillary basement membrane was found in muscles, nerves, and other organs. However, the existence of angiopathy at the capillary level of the skin of the hands and feet of the diabetic patients is still controversial.1,2 It has been shown that atherosclerotic processes demonstrate some characteristic features in the diabetic patient. They are more common in diabetics, and appear at a younger age, advance more rapidly, and are almost as common in women as in men. The atherosclerotic changes are quantitatively greater in diabetics than in nondiabetics and present a pattern of more distal arterial distribution in the arteries below the knee, as far as the plantar and arteries of the toes. This distal atherosclerotic distribution has been referred to as the disease of the small arteries in diabetics and is considered by most angiologists and vascular surgeons to be one of the main causes, together with peripheral neuropathy, of the development of the diabetic foot.3 A few years ago, LoGerfo and Coffman,1 in a lead article in the New England Journal of Medicine, challenged not only the existence of microangiopathy in the diabetic foot but also suggested that this term should be abandoned and any reference to that would be misleading and faulty.
CAPILLARY ANGIOPATHY—BALAS
DISCUSSION On the basis of the findings of Bollinger et al4 and Fagrell5 together with our observations, there is no doubt about the existence of microangiopathy, at the capillary level, in the dermis of the hands and feet of diabetic patients without the coexistence of ischemia. This condition could be coined diabetic capillary angiopathy of the dermis. The mechanism for the development of this microangiopathy is unknown. Possible vasomotor disturbances due to sympathetic neuropathy or hemorrheologic changes together with hormonal action might play a pathogenetic role. We suspect that this microangiopathy is probably responsible, at least in part, for the complications of the diabetic foot, mainly infection, but we cannot offer at present any evidence of such a pathogenetic mechanism.
CONCLUSIONS Diabetic capillary angiopathy, due to capillary changes of the dermis of the hands and feet in diabetics is an actual pathologic condition. The mechanism for its development is unknown. Efforts have to be made to clarify the pathogenetic mechanism of this microangiopathy and its role in the development and complications of the diabetic foot. Pharmacologic and other factors must be tried for reversibility of diabetic capillary changes.
REFERENCES 1. LoGerfo FW, JD Coffman: Vascular and microvascular disease of the foot in diabetes. N Engl J Med 311:1615-1619, 1984. 2. LoGerfo FW: Vascular disease, matrix abnormalities, and neuropathy. Implications for limb salvage in diabetes mellitus. J Vasc Surg 5:793-796, 1987. 3. Levin ME, LW O'Neal: The Diabetic Foot. C. V. Mosby St. Louis, 1988. 4. Bollinger A, J Frey, K Jager, K Franzeck: Diffusion through skin capillaries in patients with long-term diabetes, scleroderma and chronic venous incompetence. Int Angio 2:159-165, 1983. 5. Fagrell B: Monitoring the effects of vasoactive drugs by capillaroscopy and capillary blood flow velocity. Int Angio 2:153-158, 1983. 6. Franzeck UK, G Isenring, J Frey, A Bollinger: Video-densitometric pattern recognition of Na-fluorescein diffusion in nailfold capillary areas of patients with acrocyanosis, primary vasospastic and secondary Raynaud's phenomenon. Int Angio 2:143-152, 1983.
Downloaded by: University of British Columbia. Copyrighted material.
peripheral vascular diseases, during the last 10 or more years. Bollinger et al, by using a special technique with fluoroscein, the so-called fluoroscein microangiopathy, were able to demonstrate characteristic changes of the capillaries in diabetics.6
449
