Abstract
Objective
Although skin findings in patients with diabetes mellitus (DM) are common, many patients are unaware of these associations. A pilot study using an educational video was conducted to assess the effectiveness of a video-based tool in evaluating and enhancing the knowledge of patients with Type 2 diabetes about the cutaneous manifestations of their disease.
Methods
An instructional video in English and Spanish highlighting DM-associated skin conditions was created. This included xerosis, diabetic dermopathy, acanthosis nigricans (AN), acrochordons, infections, hidradenitis suppurativa (HS), wound healing, and cancer incidence. A convenience cohort of patients with diabetes were included. Participants completed a 10-question survey to assess their knowledge of DM-associated skin conditions either after watching the instructional video or without viewing it. A history-based questionnaire was also administered.
Results
Fourty-five participants were enrolled. Thirty participants viewed the video, and 15 controls did not prior to completing the knowledge survey. The average total score (69%) in participants who watched the video was significantly better than controls (49%). Fourty-two percent of participants reported no prior knowledge of DM-associated cutaneous effects. Greater than half of this cohort endorsed a history of xerosis, acrochordons, and diabetic dermopathy. More than 40 percent of participants affirmed having AN and infection of the skin or nails. Twenty-nine percent had a history of foot ulcers, and 13 percent had cellulitis in the past.
Limitations
This was a pilot study with a small sample size, limiting generalizability.
Conclusion
These findings demonstrate the effectiveness of bilingual video education to enhance knowledge of DM-associated skin manifestations. Given the limited awareness of and high self-reported incidence of DM-associated cutaneous disorders, accessible educational resources like this video could help patients better recognize these entities and seek appropriate treatment.
Keywords: Diabetes, patient education, cutaneous manifestations, skin conditions
INTRODUCTION
Diabetes mellitus (DM) is one of the most common metabolic disorders. This chronic condition affects 38.4 million people in the United States (US).1 Approximately 90 to 95 percent of these cases are Type 2 diabetes.1,2 While multiple organ systems are affected by this condition, a recent prospective study found cutaneous manifestations in approximately 79.2 percent of patients with diabetes.3,4 The continuum of DM-associated cutaneous conditions ranges from relatively harmless to potentially lethal diseases. Because DM-associated cutaneous findings can precede clinically diagnosed diabetes or can signal poorly controlled disease in patients with known DM, it is especially important for healthcare providers to be aware of these conditions so that appropriate action and education can be undertaken.5 Some researchers have suggested that the visible nature of these cutaneous diseases can provide added incentive for patients to control their DM.5,6 Self-management of a patient’s diabetes is a critical factor influencing the disease course and overall condition. A foundation of education and health literacy can empower patients to recognize when to seek additional assistance and intervention.7,8 Given the changing demographic and ethnic makeup of the US, it is essential that multilingual educational resources be available for patient education.9,10 Since most patients rely on their healthcare provider for information on their conditions, instructional elements should be easily accessible and understandable for distribution and use in busy clinic settings. The effectiveness of video education in enhancing health literacy and outcomes among individuals with diabetes has been previously demonstrated.11 However, little has been written about patients’ actual knowledge about DM-associated skin manifestations. We conducted a pilot study to determine if video education, available in a participant’s preferred primary language, English or Spanish, could improve awareness and knowledge of diabetes-associated cutaneous conditions.
METHODS
A total of 45 adult participants with diabetes mellitus, who were either primary English- or Spanish-speaking patients at a primary care clinic, were enrolled. Participation was voluntary, and all data were collected anonymously. Each participant had an existing diagnosis of Type 2 diabetes and was given the study materials in their preferred primary language. Approval for this study was obtained from the Lake Erie College of Osteopathic Medicine Institutional Review Board. This study was conducted at a busy family medicine clinic in a diverse, underserved area of South Florida. All participants completed an initial 10-question questionnaire that elicited data on the level of control of their disease as well as self-reported history of various common diabetes-related skin diagnoses.
Thirty patients were first shown a two-minute educational video presentation on the most common skin findings in Type 2 diabetes prior to completing a 10-question multiple choice survey that assessed knowledge of diabetes-associated skin manifestations and associations. Fifteen control participants, who did not view the educational video, were given the same 10-question multiple choice knowledge survey to assess baseline knowledge.
Topics in the educational presentation included xerosis, diabetic dermopathy, acanthosis nigricans (AN), acrochordons, infections, hidradenitis suppurativa (HS), wound healing, and risk of cancer. (See supplemental PowerPoint presentations).
Participants survey scores were calculated. A statistical analysis by t-test was performed.
RESULTS
A total of 45 patients with Type 2 diabetes completed the study. Five participants were primary Spanish-speaking and opted for all study materials (questionnaire, knowledge survey, and presentation) in Spanish. Forty participants were bilingual or primary English-speakers and opted for study materials in English. Patient history responses were recorded (Table 1). In this convenience cohort, participants self-reported previous history of various common diabetes-related skin conditions which included: xerosis (68%), acrochordons (58%), diabetic dermopathy or shin spots (58%), skin or nail infection (42%), AN (40%), and cellulitis (13%). Of the 29 percent of participants that reported having foot ulcers in the past, 61 percent stated they experienced normal healing while 39 percent said they experienced slow or poor wound healing.
TABLE 1.
Patient history questionnaire responses
| INITIAL SURVEY | N | % |
|---|---|---|
| Diabetes controlled | ||
| Yes | 17 | 38 |
| Often | 11 | 24 |
| Sometimes | 9 | 20 |
| No | 8 | 18 |
| Previous diagnosis of skin condition that you were told was diabetes-related | ||
| Yes | 10 | 22 |
| I’m not sure | 12 | 27 |
| No | 23 | 51 |
| Do you know the effects diabetes can have on your skin | ||
| Yes | 10 | 22 |
| A little, I’ve done some research | 16 | 36 |
| No | 19 | 42 |
| Suffer from dry skin | ||
| Yes | 27 | 60 |
| No | 18 | 40 |
| Have any skin tags | ||
| Yes | 26 | 58 |
| No | 19 | 42 |
| Dark, velvet-like skin on neck or skin folds | ||
| Yes | 18 | 40 |
| No | 27 | 60 |
| Previous skin/nail/toenail infections | ||
| Yes | 19 | 42 |
| No | 26 | 58 |
| Previous wounds or ulcers on feet | ||
| Yes, healed fine | 8 | 18 |
| Yes, healed slowly or poorly | 5 | 11 |
| No | 32 | 71 |
| Previous cellulitis on the leg | ||
| Yes, treated with oral antibiotics | 6 | 13 |
| Yes, treated with IV antibiotics | 0 | 0 |
| No | 38 | 87 |
| Light brown/reddish, scaly, indented patches on your lower legs | ||
| Yes | 26 | 58 |
| No | 19 | 42 |
Thirty-eight percent of the cohort stated that their diabetes was consistently under control, 18 percent felt their DM was not under control at all, and the remainder felt that their DM was often or sometimes controlled.
Only 22 percent of participants stated that their DM-associated skin conditions were diagnosed by their primary healthcare provider.
Regarding awareness, 42 percent of participants reported they had no previous knowledge of the effects that diabetes can have on the skin, 36 percent admitted to knowing only a little about effects secondary to their own research, and 22 percent said they were aware of DM-associated skin effects.
Of the 30 participants who viewed the video educational presentation, 27 were primary English speakers and three were primary Spanish speakers. Of the 15 control participants who did not watch the video, 13 were primary English speakers and two were primary Spanish speakers. All test survey results were recorded (Table 2). On each individual question, a greater percentage of video-educated participants responded correctly compared to control participants. Participants in the video-educated group scored significantly better (69% vs. 44%, p<0.01) than the control group. The average scores per cohort group are listed with and without regard to stated prior knowledge (Table 3). Independent of prior stated knowledge, the video-educated group scored significantly higher compared to the control group.
TABLE 2.
Knowledge survey results
| TEST SURVEY RESULTS | NO VIDEO EDUCATION N (%) |
VIDEO EDUCATION N (%) |
|---|---|---|
| Dry skin (xerosis) is present in what % of patients with diabetes | ||
| Correct | 2 (13) | 16 (53) |
| Incorrect | 13 (87) | 14 (47) |
| How can you reduce symptoms of xerosis | ||
| Correct | 4 (27) | 22 (73) |
| Incorrect | 11 (73) | 8 (27) |
| In a recent study, skin disorders are present in what % of patients with diabetes | ||
| Correct | 3 (20) | 11 (37) |
| Incorrect | 12 (80) | 19 (63) |
| Most common type of fungal infection in patients with diabetes | ||
| Correct | 10 (67) | 29 (97) |
| Incorrect | 5 (33) | 1 (3) |
| Groin infection is most common soft tissue infection in patients with diabetes: true or false | ||
| Correct | 8 (53) | 17 (57) |
| Incorrect | 7 (47) | 13 (43) |
| Low HbA1c is associated with this condition (shown photo of AN): true or false | ||
| Correct | 9 (60) | 24 (80) |
| Incorrect | 6 (40) | 6 (20) |
| Select true statement about foot infections in patients with diabetes | ||
| Correct | 13 (87) | 30 (100) |
| Incorrect | 2 (13) | 0 (0) |
| Diabetes/high blood sugar is associated with improved wound healing: true or false | ||
| Correct | 10 (67) | 27 (90) |
| Incorrect | 5 (33) | 3 (10) |
| Skin conditions associated with diabetes: check all that apply | ||
| Correct | 0 (0) | 7 (23) |
| Incorrect | 15 (100) | 23 (77) |
| Association between diabetes and cancer risk | ||
| Correct | 10 (67) | 25 (83) |
| Incorrect | 5 (33) | 5 (17) |
TABLE 3.
Knowledge survey score averages
| TEST SURVEY RESULTS | NO VIDEO EDUCATION (% CORRECT) |
VIDEO EDUCATION (% CORRECT) |
|---|---|---|
| Previous knowledge of diabetic skin conditions | ||
| Yes | 30 | 65 |
| A little, I’ve done some research | 45 | 76 |
| No | 47 | 65 |
DISCUSSION
DM has several associated cutaneous manifestations. In our study, we highlighted a few of the most common conditions: xerosis, diabetic dermopathy, AN, acrochordons, HS, and cutaneous infections, including dermatophytes, as well as bacterial infections. Twenty-six to 44 percent of patients with Type 2 diabetes suffer from xerosis, or dry skin, which has been found to be associated with microvascular complications of the disease.3,12,13 Diabetic dermopathy, hyperpigmented macules found on the extensor surface of the lower legs, has been found to affect 39 percent of patients with Type 2 diabetes.3,14 It is proposed that diabetic dermopathy is the result of microvascular complications due to microangiopathic changes as well as hemosiderin and melanin deposition.13 Skin tags, or acrochordons, are benign lesions common in 25 percent of all adults but have an association with insulin-resistant states.3,14 Epidermal growth factor and alpha tissue growth factor can be triggers for acrochordons. While the association of acrochordons and diabetes has been repeatedly observed, the precise etiology is unknown.13,15 AN presents as velvety, hyperpigmented, thickened skin commonly found on the neck and skin folds and affects 47 percent of patients with Type 2 diabetes.3,14,16 The pathogenesis of diabetes-associated AN is not completely understood. It is suggested that the hyper-insulin state activates insulin growth factor receptors on keratinocytes and fibroblasts, which in turn provokes cell proliferation leading to the cutaneous findings of AN.13 HS is a chronic condition characterized by painful, inflamed nodules and abscesses found in intertriginous regions of the body.13 DM is three-times more common in patients with HS compared to the general population, although the exact cause is unknown.13,17 In patients wtih DM, skin infections occur in 61 percent of patients.3 In patients with uncontrolled diabetes, risk factors for infection include cell abnormalities in innate immunity, angiopathy, neuropathy, as well as the promotion of pathogen growth in a glucose-rich environment.13 Dermatophytes and bacterial infections such as cellulitis are commonly observed in patients with DM. Of note, complications in infected foot ulcers can have life-threatening outcomes.3 As these conditions are ubiquitous in this population, education is crucial for proper identification and treatment. Self-management and collaboration with healthcare providers are key determinants in the control of diabetes. Unfortunately, 15 to 40 percent of patients with diabetes possess a low level of health literacy, which is correlated with poor outcomes.18 A gap in patient education and diagnosis within primary care settings is highlighted by the fact that only 22 percent of participants reported their DM-associated skin conditions had been identified by their primary healthcare provider. Increasing the focus on cutaneous manifestations of diabetes during primary care visits could improve early recognition and management. To best educate patients with DM about skin manifestations, teaching elements should be accessible and easy to understand so patients can readily recognize cutaneous conditions and seek appropriate intervention. In our study, many participants acknowledged they did not have prior formal knowledge on this topic. With our educational video, we were able to address this knowledge gap and improve health literacy by effectively educating participants about associated skin manifestations of Type 2 diabetes.
LIMITATIONS
This study was conducted at a single clinical site with a relatively small sample size, which limits the generalizability of the findings. The results of this study might not be broadly applicable to other geographical areas or different clinical settings. Furthermore, the characteristics of the patient population at this site might not be representative of larger populations, thereby restricting the external validity of the findings. Future research involving larger, more diverse samples from multiple sites is needed to corroborate and extend the conclusions drawn from this preliminary study.
CONCLUSION
As the demographic makeup of the US is changing, it is important that we have practical teaching resources that are well-received, understandable, and language-inclusive to improve health literacy and positively impact patient outcomes. The low patient reported rate of primary care identification of DM-related skin conditions suggests that integrating skin health education into routine diabetes care could improve diagnostic rates and patient knowledge. The utilization of a brief video presentation as an educational resource can be an effective instructional method in busy clinic settings.
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