Acanthosis nigricans, diabetic foot ulcer in Indigenous populations
Scoping review suggests more attention to cutaneous complications of diabetes is needed (1,900 words, 9 minutes)
There is a need for greater recognition of diabetic skin complications in North American Indigenous populations as well as barriers to care, Dr. Jordanna Roesler told attendees at the second annual Indigenous Skin Spectrum Summit on June 11, 2022.
Dr. Roesler is a dermatology resident at the University of British Columbia in Vancouver and a member of Saskatchewan’s Dene First Nation. The findings she cited are from a scoping review that has not yet been published.
She and her colleagues reviewed 21 primary articles published between 1989 and the present. Most articles represented rural North American Indigenous (NAI) populations. The Canadian studies focused on northern Manitoba and a Winnipeg tertiary care centre. Researchers chose studies with methods, results, and discussion focused on Indigenous populations. She said the most common designs were observational studies, case series, retrospective chart reviews, and epidemiologic studies.
Acanthosis nigricans (AN) and diabetic foot complications were two major themes identified in the literature.
Dr. Roesler noted that AN is associated with insulin resistance, so it is important to screen for diabetes in patients who present with hyperpigmented velvety plaques in the skin folds. This is especially true when patients have a family history of, or current cardiovascular disease or obesity, she said.
Community-based observational studies showed a high prevalence of AN in some NAI communities, associated with both obesity and diabetes risk in adult and pediatric patients. The burden of disease can be reduced by early diagnosis and treatment, she said.
As for foot complications, Dr. Roesler said: “When looking at population-based epidemiologic studies, NAI people have the highest prevalence rates of diabetic foot ulceration and lower limb amputation secondary to diabetes in comparison to other racial groups in the United States.”
She said this high rate of diabetic complications shows a clear need for early detection and intervention since living on reserve is correlated to a shorter average time to major lower extremity amputation.
Indigenous populations may face unique social and environmental determinants of health that contribute to higher rates of diabetic complications. These determinants include poor access to primary healthcare, a lack of therapeutic footwear programs, and poor access to and the high cost of nutritious food.
Some studies identified in the review point to ways outcomes in Indigenous communities can be improved, Dr. Roesler said.
“Indigenous philosophy, beliefs, and practices influence self-care and healing for diabetic foot ulcers, as do onsite preventative care and screening by travelling diabetic foot nurses in remote communities,” she said.
The review identified several ways that the involvement of the Indigenous community itself could lead to improved outcomes, including:
Employing Indigenous community members as study coordinators to improve communication during research.
During study development, consulting with community members on study design and providing ongoing input throughout the entire project.
Working with community leaders to develop culturally appropriate service announcements and recruitment tools.
Bottom Line: A systematic scoping review showed the need for increased recognition of diabetic skin disease and foot complications in North American Indigenous populations. A better understanding of the unique barriers and social determinants of health faced by many Indigenous peoples is needed. Increased community engagement and guidance may be successful strategies.
From the literature on diabetes and acanthosis nigricans
Associations between racial and ethnic groups and foot self-inspection in people with diabetes
The authors of this paper note that race and ethnicity are strongly associated with the risk of lower limb amputation in diabetes and that daily foot self-inspection may permit earlier detection and treatment, reducing the risk of infection and amputation. Through this paper, investigators aimed to assess the differences in foot self-inspection among people with diabetes by race and ethnicity.
Using U.S. national data from the 2015 to 2017 Behavioral Risk Factor Surveillance System surveys, the authors included records on 88,424 individuals with diabetes. Working with this data, they estimated prevalence ratios (PRs) and associated 95% confidence intervals (CIs) of daily foot checking for sores or irritation by racial and ethnic groups.
The authors found that compared to White individuals, African Americans, American Indians or Alaska Natives, and Native Hawaiians or Pacific Islanders had a higher prevalence of daily foot self-inspection. However, these inspections were lower in Asians and Hispanics compared to Whites.
These associations did not vary significantly with regards to insulin use, years since the diagnosis of diabetes, or whether the patient had received diabetes self-management education.
The authors conclude that an elevated prevalence of foot self-inspection is insufficient to counter the disparities in lower limb amputations due to diabetes in racial and ethnic groups.
Prevalence of acanthosis nigricans and its association with physical activity in adolescents—School-based analytical cross-sectional study from Kochi, Kerala
This cross-sectional study was conducted in two grades of a school in the Ernakulam district of Kochi in India between June and Dec. 2018. The participants included 400 adolescents aged 13 to 14 years. Participants self-administered the Physical activity questionnaire, Adolescents (PAQ-Adolescents), and the principal investigator confirmed the presence of acanthosis nigricans (AN).
The researchers determined the overall prevalence of AN was 14.5%, being most prevalent among obese adolescents (61.54%), adolescents with low exercise rate (23.94%), those with a family history of diabetes (21.18%), a family history of hypertension (21.86%), and a family history of both diabetes and hypertension (26.32%). The risk factors that had a positive association with AN also had a negative association with physical activity. There were no reported cases of AN among adolescents with increased exercise rates.
Regular adequate physical activity can prevent the onset of AN and
thereby reduce the early onset of diabetes and other complications, the authors conclude.
Prevalence, determinants and perception of the use of skin lightening products among female medical undergraduates in Nigeria
The authors of this paper note that the use of skin lightening products (SLPs) is common in Africa, especially
in Nigeria. In addition to cutaneous side effects, they write these products have several potentially severe systemic effects, including diabetes mellitus, Cushing's syndrome, hypertension, organ failure involving the kidneys and liver, cancers, and eye complications.
A total of 110 respondents completed an online survey of female medical students in Nigeria to identify their history, pattern, and perception of the use of skin lightening products (SLPs).
Roughly 40% of respondents (45/110) reported they used SLPs, with facial cleansers the most common type used [23/45 (51.1%)]. More than 80% of participants knew SLPs could cause adverse effects, with ‘skin irritation most commonly identified [71/110 (64.5%)].
Although most (80%) respondents did not report that they thought light skin was superior to dark skin, "removal of discoloration/dark spots" (40%) and "cosmetic reasons" (37.8%) were the most common reasons for use.
Use of SLPs was associated with light skin colour (OR 3.8, 1.572–9.318), history of use among relatives (OR 3.3, 1.384–7.793), and awareness of adverse effects (OR 3.3, 1.129–9.740).
Topical rapamycin for acanthosis nigricans in the Fitzpatrick IV/V adolescent population
FGFR3 mutations can lead to acanthosis nigricans (AN), epidermal nevi, and seborrheic keratosis, note the authors of this paper.
They report a case of an 18-year-old female patient with Fitzpatrick skin type (FST) IV/V and FGFR3-induced hypochondroplasia who presented with extensive AN-like plaques. A treatment regimen
t of 1% topical rapamycin cream, twice daily, resulted in significant lightening and thinning of the plaques.
The authors write that this case expands on earlier findings that topical rapamycin can improve FGFR3-induced epidermal nevi with AN features in children with FST I/II.
They conclude that topical rapamycin should be considered a treatment option for AN, particularly in FST IV/V adolescents with FGFR3-induced AN.
VIDEO: Doctor V—How to treat acanthosis nigricans | Skin of colour | Brown or black skin
At the intersection of skin and society
“As I was writing and then going into production for Bones of Crows, more and more residential school children were being found across Canada in unmarked graves,” writes Clements. “The film was meant to speak to the multi-generational legacy of the residential school experience—but there was no way of knowing how impactful it would be to be shooting scenes in the Kamloops Residential School while also watching hundreds of people come to the memorial set up outside of the school in response to the bodies of 215 residential school students being found.”
Clements was born in Vancouver. As writer, showrunner, and director, her works include the shorts Jesus Indian (2010) and Pilgrims (2013), the documentary shorts The Language of Love (2012) and Looking at Edward Curtis (2018), the documentary feature The Road Forward (2017), and the fiction feature Red Snow (2019). Bones of Crows (2022) is her latest film and was screened at the 2022 Toronto International Film Festival.
Bones of Crows is the largest production on the residential school experience written, directed, and produced by an Indigenous creator, Clements notes.
“It is the first time we will be able to see ourselves—our grandmothers and grandfathers, our parents, aunties, and uncles, over a span of 100 years while also being modern in the time that they were alive.”
She notes that Indigenous Canadians do not have a record in film that shows them as part of history. However, she writes that many have photographic records in family albums that show how Indigenous people have been part of the country’s history all along.
“There are war heroes and seamed nylons, Indian cowboys, straight skirts, tattoos, and horn-rimmed glasses. There are black-haired bee-hives and tailored suits, palazzo pants, and mustang bikes,” she writes. “There are politics and wars, human rights movements and traditional realities. This film is a generational period piece coming up through the decades, asserting that our future was always present, our past always connected to the future.”
Bones of Crows is a response to Indigenous peoples’ lived history in Canada. Its story tells the hard truths of starvation, disease warfare, sterilization, residential schools, the Sixties Scoop, Murdered and Missing Indigenous Women and Girls, poverty, the incarceration of Indigenous people, environmental crisis, and the foster care system, she writes.
Sept. 21 is International Day of Peace
Sept. 19 to 23 is Malnutrition Awareness Week
Sept. 25 is World Pharmacist Day
Something to think about in the week ahead…
John Burroughs, American author
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