Skin - Allpresan

Transcription

Skin - Allpresan

Clinical Guidelines
Diabetes and the Skin
A Handbook for the Clinic
June 2011
511011
Authors: Dr Rainer Thiede, Dr Martin Lederle, Prof Rolf Daniels
2nd edition
with 8 extra
pages on
skin
care
Clinical Guidelines: Diabetes and the Skin
Page
3 Skin Disorders in Diabetes
Page
4 Infections of the Skin
Good Skin at a
Glance
Page 10 Skin Disorders Associated with Diabetes
Page 18 Acute Diabetic Foot Syndrome
Page 27 Clinical Photographs
Cleansing of the skin in people with diabetes should
be carried out using pH-neutral preparations. Products
containing artificial fragrances, colours and preservatives should be avoided as far as possible.
Page 33 Complications with Diabetes Therapy
Page 35 Skin Care and Diabetes
Page 43 Useful Facts on Cosmetic Ingredients
Page 51 Useful Addresses
Diabetes is not only one of the
most common diseases of our
time, but one of the most costly to treat. It belongs to the
group of so-called diseases of
modern civilization (cardiovascular disease, obesity, etc.), better known as Syndrome X, that
are considered to be holding
our society hostage — their prevalence having reached epidemic proportions.
Nearly every diabetic experiences characteristic skin problems at some time during the
course of the disease. Quite
commonly, skin manifestations represent the first indications of the presence of diabetes. This manual introduces the
reader to some of the most important skin problems typical to
diabetes, with emphasis on the
clinical environment, including
many informative illustrations.
Contained in this book is also
a descriptive list of the main ingredients of skin care products
to serve as an easy reference
for the reader.
With this handbook, we wish
you pleasant reading and hope to provide you with a practical guide to your daily work in
the clinic.
Bathing should be limited, and the ideal water temperature should lie between 30° and 35° C. Very hot
water should be avoided. Also, showers should be
short, using cool water. A soft towel should be used
for drying the skin. Wrinkles should be dabbed and
not wiped, and skin in crevaces must be dried meticulously. A linen cloth should be placed under skin
folds, such as under the breasts, to prevent the build
up of moisture.
In order to avoid mycotic infections, socks should be
changed daily, and always washed at a temperature
of 60° C. Studies have shown that boiling the wash
ing is deemed unnecessary as certain fungi are effectively destroyed at a temperature of 60° C. Nylon
stockings are a breeding ground for fungi. As nylon stockings cannot usually be washed in hot water, spores can remain in the stockings over a matter
of weeks. Going barefoot should also be avoided.
In principle, adequate physical exercise and all-round
good metabolic control should be aimed for.
The Authors
Impressum: © Kirchheim
Dr Rainer Thiede, Dermatologist,
Kevelaer, Germany.
Kirchheim Publishers, Mainz
(2011), 2nd edition
People with diabetes should regularly examine their feet for any problem signs.
Authors:
Dr Rainer Thiede,
Dr Martin Lederle,
Prof Rolf Daniels
In order to avoid mycotic infections, socks should be changed
daily, and always washed at a
temperature of 60° C.
Coordination: Matthias Heinz;
Production: Reiner Wolf;
Print: Hofmann Infocom,
90411 Nürnberg
Kirchheim + Co GmbH
Kaiserstrasse 41
D-55116 Mainz
Dr Martin Lederle, Diabetologist,
Stadtlohn, Germany.
Courtesy of neubourg skin care
GmbH & Co. KG.
A moisturizer should be applied regularly with a cream
or lotion free of fragrances, colours and preservatives.
The feet need special care and daily inspection. If the
mobility of the patient is limited, a telescopic mirror can be used. Care of the feet and toenails is indispensible, and should be carried out by an experienced podiatrist. The shoes should also be regularly
checked for foreign particles or defects.
Skin
Skin Disorders in Diabetes
The skin of people with diabetes tends to have
a soft and withered consistency. The skin of diabetics ages and develops wrinkles more rapidly. The skin of diabetics is, per se, quite dry and
flakes easily.
The causes of specific skin disorders lie in circulatory problems due to micro- and macroangio
pathy, diabetic polyneuropathy with neurolo
gical changes such as sensory disorders, and a
weakened immune system.
What it is about the diabetic metabolic state
that causes skin disorders is still being debated.
It is established, however, that premature ageing is caused by a slowed function of the sweat
and sebaceous glands, a reduction in the skin’s
ability to retain moisture, under-developed keratinocytes1 (due to lack of insulin), and reduced
cutaneous immunity.
Skin disorders in people with diabetes are usually categorized into three groups:
1. skin infections,
2. skin afflictions typical to diabetes, and
3. the diabetic foot.
1
Keratinocyte = epidermal cell
The skin of people with diabetes is considerably dry.
© Kirchheim-Verlag, Mainz • Clinical Guidelines (2011) • Skin
3
Skin
Infections of the Skin
Due to their weakened immunity (reduced function of the defence cells and antibody production), diabetics are considerably more vulnerable to mycotic and bacterial infections. Hyperglycaemia (the epidermal glucose content is 3565% that of the blood glucose level), neuro
pathy and dry skin also contribute to the skin’s
susceptibility. In this way, the diabetic metabolic
state is an absolute hotbed for the building of
local infections. Lesions are more common and
more severe in diabetics than in non-diabetics,
and are much harder to heal.
Trichophyton mentagrophytes.
Fortunately, diabetics with well controlled metabolic states are at no higher risk of contracting such skin infections as mentioned here than their
non-diabetic peers.
Tinea pedis.
4
Skin
Onychomycoses.
Fungal Infections of the Skin
Dermatophytes
Pathogenic fungi can generally be divided up
into three groups according to the DYM s ystem
(dermatophytes, yeasts, moulds, see page 7).
Dermatophytes are mainly responsible for fungal infections on the feet and legs, as well as on
the body, and are mostly made up of microbes
called trichophyton rubrum and trichophyton
mentagrophytes. It usually manifests first and
foremost between the toes, especially between
the fourth and fifth (interdigital mycosis). Whitecoloured fissures or fine lamellar scaling first appear that can eventually spread across the whole
foot (tinea pedis).
From its focal point, tinea develops centrifugally
as a sharply demarcated area of flaky skin. The
difference between an outbreak of tinea pedis
Moist, macerated areas must be kept
dry. An association between a poor diabetes control and the development
of mycoses has long been established.
A well controlled metabolic state is,
therefore, the best prophylaxis.
Tinea corporis.
5
Skin
Candida infections.
and extremely dry skin is often not possible without the help of a mycological diagnosis. Mycosis is not to be taken lightly in the case of diabetics. On the one hand, the tiny fissures in the
skin provide an opening for streptococci, that
can lead to erysepelas. On the other hand, interdigital mycosis, if left untreated, can spread to
the toenails (onychomycosis). This condition can
also form a reservoir for pathogens which can
be scattered around with every change of socks
or stockings. Hence, tinea corporis can spread
across the entire integumentary system.
Antimycotic creams must not be used prior to a
clinical diagnosis of fungal infections. This applies also to the nails, as many people can buy
an array of antimycotics over-the-counter and
try home treatment prior to seeing a physician.
A six-week time lapse without therapy must be
6
adhered to before a sample is taken for examination.
The sample should be taken towards the outer
edge of the skin or nail infection. With mycosis of the nails, the sample should be taken subungual, i.e., from under the nail. Because the
dermatophytes grow very slowly, it can take as
long as six weeks for a conclusive result to be
obtained from the culture.
Treatment of fungal infections usually consists
of topical administration of antimycotics. If the
infection is particularly therapy resistant, or afflicts the whole body, systemic treatments are
preferred.
Skin
Tinea corporis.
Perleche.
Yeasts
Yeast colonies are usually found on areas of the
body where skin meets skin, leading to an occlusive effect. It is in such moist environments
that yeasts thrive. Ideal locations are, for example, under the breasts, under the arms, the groin
region, the corners of the mouth (perleche), inside the mouth, and genitals.
It is important that the fungal infection
is not treated with any antimycotic applications before being d
iagnosed. This
applies also to the nails, as many patients treat their skin and nails with
an array of over-the-counter medications beforehand.
DYM: Dermatophytes – Yeasts – Moulds
DYM is one of the most commonly accepted systems of categorization used in medical mycology
for the clinical diagnosis and treatment of mycoses. This table presents a sample of pathological
fungi using the DYM system.
D
Y
M
Trichophyton
Candida albicans
Aspergillus fumigatus
T. mentagrophytes
C. tropicalis
A. niger
T. verrucosium
C. glabrata
Scopulatiopsis species
Microsporum canis
Trichosporon species
Cephalosporium species
M. gypseum
Rhodotorula species
M. audouinii
Cryptococcus species
Epidermophyton floccosum
Pitrosporum species
7
Skin
Bacterial Infections
Erysipelas
Erysipelas appears as an extensive rash. The
point of outbreak is usually some kind of skin
defect such as a discreet case of interdigital mycosis between the toes that serves as point of
entry for streptococcal bacteria. The streptococci penetrate the injury and spread across the
skin, manifesting in the classic clinical symptoms
of an area of sharply demarcated redness. Fur-
ther to this, the patients often complain of fever and chills. It is more difficult to diagnose recurring erysipelas, as the clinical symptoms are
less obvious; fever and chills are hardly discernable. It is best to avoid a recurrence of erysipelas if at all possible, as repeated infections in
the vessels can cause adhesions which can lead
to lymphoedema.
Penicillin is and always has been the
preferred treatment for erysipelas. The
affected region should be rested. Sanitization of the point of entry contributes considerably to therapeutical success and helps to prevent recurrence.
Erysipelas associated with the diabetic foot.
8
Skin
Abscesses, furuncles,
carbuncles
These bacterial skin infections are fluctuant,
caused mainly by staphylococci, and usually
start out in a hair follicle. They can be treated
operatively (according to the adage often cited in medicine, “ubi pus ibi evacua” = “where
there is pus, there evacuate it”), or systemically
with antibiotics on the basis of an antibiogram.
A rarity, but exclusive to people with
diabetes, is malignant otitis externa.
It is triggered by pseudomonas aeruginosa. The diagnosis is reached by
means of bacterial culture. It is treated
systemically--according to the results
of an antibiogram--with antibiotics.
9
Skin
Skin Disorders Associated
with Diabetes
Necrobiosis lipoidica
Necrobiosis lipoidica is an inflammatory reaction
that tends to appear on the shins. In rare cases,
the arch of the foot is afflicted. Cases have been
reported on other parts of the body, but this is
considered exceptional. It appears as a pretibial2, sharply demarcated, rough, yellowy-red efflorescence3, that can spread centrifugally to
saucer size. In its centre, the skin becomes thin
and tiny blood vessels appear (teleangiectasia).
The skin in the centre becomes more and more
fragile until--as occurs in around one-third of
the cases--ulceration appears within the necrobiosis lipoidica. Some sort of injury to the area is
usually responsible for triggering the ulceration.
Necrobiosis lipoidica is treated mainly with compression therapy, nicotine abstinence, protection
from injury, as well as a stage-adapted wound
care. Steroids administered locally or intrafocal-
Necrobiosis lipoidica.
Pruritus diabeticorum
Necrobiosis lipoidica occurs three times
more frequently in women than in
men.
ly4 offer a further mode of treatment. In general, necrobiosis lipoidica is difficult to treat, even
when there is no connection to diabetes.
10
2
pretibial = on the shin
3
efflorescence = skin eruption
4
intrafocal = within a wound
Itching is a common symptom amongst diabetics, especially on the feet, lower limbs, as well
as on the back. Even in non-diabetics, increasing age causes a physiological regression of the
gland function in the lower limbs, causing dry
skin. This leads to the development of asteatotic
eczema. The flakey scales on the surface of the
skin, that look like badly laid paving stones, irritate the underlying nerve endings. This triggers itching, the patient scratches himself, and
so a vicious cycle begins.
Being so therapy resistant, vulvovaginal itching
is a case in itself where the patient is often sent
on a lengthy odyssey that can end up in the diagnosis of diabetes. In this way, insistent vulvo-
Skin
Pruritus with eczema.
vaginal itching can actually be an indication of
undiagnosed diabetes.
Prurigo diabeticorum
If the aforementioned pruritus diabeticorum is
left unattended, it can cause the patient to have
severe scratching attacks. This scratching leads
to the development of pruritic nodules (prurigo
nodularis), which can become as big as a pea,
and are found in the areas of the body accessible to the patient. This observation is important in the clinical diagnosis of this condition,
as the symptoms are very similar to the everincreasing disease of scabies, the only difference being that in scabies, the symptoms appear also in bodily areas that are not accessible
to the patient.
A correlation between pruritus diabeticorum and the diabetic metabolic state
has not been established. Optimal diabetes control does not necessarily accelerate the healing process.
Pruritus diabeticorum.
Perforating dermatosis
In this condition, hyperkeratosic papules and
nodules appear, partly umbilicated and, as a
rule, lineally arranged. This skin disorder is found
mainly on the extensor sides of the lower extremities. It is often accompanied by itching.
Diabetic dermopathy
Diabetic dermopathy (shin spots) appears in
around 15% of diabetics. These reddish-brown
spots are asymptomatic and slightly atrophic.
They usually heal after a few years without leaving scars.
Acanthosis nigricans benigna
Acanthosis nigricans benigna manifests as a
patch of hyperkeratotic, velvety brown, which
appears on the neck, the armpits, or the groin.
It normally neither hurts nor itches. As it appears
like a patch of dirt, the patients sometimes find
their way into the clinic because they were unable to ‘wash’ this patch of dirt off. This condition is present in around 90% of young type 2
11
Skin
Acanthosis nigricans.
diabetics, and also in overweight youths. Clinically, it is important to eliminate the presence
of acanthosis nigricans maligna, which can be
an indication of stomach tumour, namely, adenocarcinoma of the bowel. This form is identifiable by the rapid proliferation of the skin anomaly, as well as a palmoplantar and/or mucocutaneous manifestation.
Topical therapy with retinoic acid is
worth trying in the treatment of acanthosis nigricans. However, losing and
maintaining normal weight has proven to be the most effective approach.
Diabetic dermopathy.
12
Skin
Cheiroarthropathy
diabeticorum
Cheiroarthropathy diabeticorum is characterized by a painless stiffening of the hands and
fingers, limiting their movement. Usually, both
hands are afflicted at the same time, and the
symptoms symmetrical. Due to the stiffness, the
hands can no longer be stretched out flat. This
is why this condition is sometimes named as the
‘prayer sign’ or ‘table top sign’. A specific therapy for this disorder is not known. Physiotherapy is usually prescribed.
fects mostly elderly diabetics who have had diabetes over a long period of time. However, in
severe cases, a hardening of the thorax can occur, whereby the patient has massive trouble
breathing. Hence, it is important that physiotherapy be prescribed early on.
Other forms of scleroedema diabeticorum
should be eliminated that, for example, occur
as a result of acute infection (scleroedema adultorum of Buschke).
Bullosis diabeticorum
Scleroedema adultorum
Scleroedema adultorum is known as a condition
where non-itching, painless swelling and indurations appear on the neck, as well as on the
back. In time, this efflorescence can spread to
the face and chest, and to the entire back. The
skin appears as orange peel. This condition af-
These diabetic non-itching and painless blisters
appear spontaneously and mostly on the wrists
and arches of the feet. They are filled with clear
fluid. Typically, the surrounding skin is healthy
and unaffected. Recommended treatment is
to aspire the blisters using a sterile technique,
whilst keeping the blister intact as a natural protective cover. Specific therapy is unnecessary, as
Patients with the ‘prayer sign’ are 10
times as likely to suffer from retino
pathy, cardiovascular disease and ne
phropathy.
Bullosis diabeticorum.
13
Skin
the condition is self-limiting and heals usually
within a matter of weeks, scar free. An association between bullosis diabeticorum and the metabolic state has not been able to be detected.
It may be triggered by microinjury, or by light.
As bullosis diabeticorum is diagnosed
by exclusion, it is important to eliminate other blister-forming diseases, especially if they appear on parts of the
body other than the hands and feet,
as this is where bullosis diabeticorum
tends to localize.
Eruptive xanthomas
Eruptive xanthomas are crops of millimetric, yellowish-red, soft, fatty deposits in the skin. They
usually appear symmetrically on the extensor
sides of the extremities. Itching is rare. Their
appearance seems to correlate with hyperlipidaemia.
Treatment of eruptive xanthomas involves stabilizing the underlying diabetic hyperlipidaemic
state either with dietary measures or medicinally. In this way, the depositions should disappear
within a matter of months. If the eruptions fail
to heal, or are cosmetically disturbing, operative
treatment should be considered. Very favourable results have been achieved using ablative
lasers such as CO2 or Erbium-Yag laser devices.
Rubeosis faciei
Appearing frequently in diabetics, but not diabetes-specific, is rubeosis faciei, which manifests as flushing on the face which can, under
certain circumstances, spread to the shoulders
and arms. The flushing can also be accompanied
by oedematous swelling.
14
Palmar erythaema
Palmar erythaema appears similar to rubeosis
faciei, except that the flushing occurs on the
inside of the hands instead of on the face. The
flushing appears mainly on the thumbs and pads
of the little fingers. Although this anomaly appears frequently in people with diabetes, it is also associated with an array of other underlying
conditions such as heart failure, hepatopathy,
hyperthyreosis, pregnancy, malnutrition, colitis
ulcerosa, etc., and is therefore not considered
diabetes-specific.
Psoriasis vulgaris
Recent studies emanating from England have
found that psoriasis vulgaris manifests two-tothree times more frequently in diabetics than
in their non-diabetic peers. The correlation was
more pronounced with increased severity. It has
been established, in recent years, that psoriasis vulgaris represents an inflammatory disease.
Patients with this condition tend to suffer from
the classic risk factors such as lipidaemia, high
blood pressure and overweight. These risk factors are known as syndrome X, and are considered to be the main contributors in the development of arteriosclerosis. This inflammatory
process triggers the release of substances that
hinder the insulin effect on the cells. Thus, with
time, this insulin resistance develops into fullyfledged diabetes.
Psoriasis vulgaris is characterized by well defined, flaky, silvery plaques, that appear on the
scalp and behind the ears, on the elbows, on
the knees, under the breasts and around the
anus (on these atypical places, the psoriasis is
named psoriasis inversa). The diagnosis of psoriasis vulgaris is usually carried out by anamneses
and clinical findings. The condition is genetic.
Skin
Palmar erythaema.
Fibroma pendulans
Individual studies have shown a correlation between the presence of fibroma pendulans and
diabetes. This condition describes skin-coloured,
shaft-like or wart-like skin tags that mainly ap-
Patients with psoriasis vulgaris tend
to suffer from the classic risk factors: lipidaemia, high blood pressure,
overweight.
pear on the eyelids, the neck, under the arms,
and in the groin region. These growths are completely harmless, but are considered a nuisance
by most patients. They can be removed by a simple surgical procedure.
Erythromelalgia
Erythromelalgia is an incidental condition, characterized by areas of red, painful, and burning
skin. Besides cooling, there is no specific therapy.
Psoriasis vulgaris.
15
Skin
Fibroma pendulans.
Granuloma annulare
disseminatum
Granuloma annulare disseminatum is a ringed,
mostly skin-coloured group of nodules with
sunken centres. This condition is asymptomatic, and mainly appears on the back of the hands
and feet. In diabetics, one usually finds several outbreaks.
16
In 75% of the cases, the condition heals by itself within two years. Further therapeutical options are topical steroids as well as phototherapy (PUVA-psoralen and UVA therapy).
Skin
Granuloma annulare.
17
Diabetic Foot Syndrome
Acute Diabetic Foot Syndrome
Causes, Diagnosis and Therapy
Diabetes: A Disease of Modern Civilization
In 2006, an estimated 7.1 million people were
living in Germany with diagnosed diabetes. Not
all people with diabetes suffer from diabetic
foot. This figure lies somewhere between 2%
and 7%.
What is Diabetic Foot?
Diabetic foot refers to a lesion, injury, or disor
der that occurs beneath the knee joint in peo
ple with diabetes, which can take the follow
ing forms:
–– an acute lesion (pressure ulcer, infected
wound, callus haematoma),
–– a chronic wound (over six weeks) with no hea
ling tendency,
Incidence of diabetes-related conditions that can lead to the diabetic
foot syndrome:
Diabetic Neuropathy
approx. 50 %
Arterial Insufficiency
approx. 15 %
Combination
approx. 35 %
Diabetic Microangiopathy5 plays no
role in the development of foot lesions.
5
Diabetic microangiopathy = changes of the small arteries, which are clearly revealed by histological examination. Diabetic microangiopathy is responsible for diabetic
retinopathy = changes in the retina, and diabetic nephropathy = changes in the kidneys.
18
–– a diabetic neuropathic osteoarthropathy
(DNOAP) with at least two clinical signs (heat,
swelling, pain, redness) or a radiological fin
ding, or
–– a post-amputative condition with vulnerable
stump or extremely tender scar from a healed
ulcer.
Diabetic foot syndrome appears amid the
context of diabetic neuropathy and/or venous
insufficiency in the legs.
According to a Statuary Health Insureancefund
report (Wissenschaftliches Institut der Ortskran
kenkassen), 32,000 people with diabetes under
went minor amputations (below the ankle) and
major amputations (above the ankle) in Germa
ny in the year 2003.
People with diabetes are highly vulnerable for
the following reasons:
–– The rate of recurrence for a foot lesion is ve
ry high: Around 70% of patients suffer from
a new foot lesion within five years.
–– Around 50% of patients that have undergone
an amputation due to the diabetic foot syn
drome will require another one on the other
limb within four years.
–– Over 70% of patients are unable to return
home after having undergone a foot ampu
tation.
–– Around 50% of patients die within three y ears
of undergoing an amputation.
Despite the above, it has also been establish
ed that, with early intervention and proper
treatment, at least 50% of amputations can
be prevented.
▶▶An additional amputation on the right foot
After the patient had already lost part of the right foot due to diabetic foot syndrome, the appearance of another deep lesion on the sole in the presence of diabetic neuropathy led to a complete foot amputation.
Diabetic neuropathy
▶▶Diabetic Neuropathy
Diabetic neuropathy is the result of long-term
(over months to years), chronic hyperglycaemia
which, over time, leads to nerve damage.
In the foot, all nerve types (motor, sensory, autonomic) can be affected.
Types of Podiatric Diabetic Neuropathy:
Motoric Neuropathy: atrophy of the
small muscles of the feet; plantar
subluxation of the heads of the metatarsal bones; the toes are drawn
towards the arch of the foot
Sensory Neuropathy: reduced sensitivity to pain
Autonomic Neuropathy: reduced perspiration
A typical feature of diabetic neuropathy:
The heads of the metatarsal bones subluxate towards the sole, drawing the toes
toward the arch of the foot.
19
▶▶Hyperkeratosis on the tip of the left big toe.
The left foot of the patient is
longer than the right foot. If
the shoes are the same size,
the tip of the left big toe
chafes on the inner lining of
the left shoe, resulting in adaptive hyperkeratosis.
The changes that occur due to diabetic neuropathy can alter its gait on walking, that is, the
way the foot rolls6. The balls of the big toe and
the little toe bear more of the burden, and the
middle toes less. Due to this increase in load, the
affected areas develop a thickening and hardening of the outer skin layer (hyperkeratosis7).
In the above illustrations, one can see that the
claw toe on the right foot extends plantarically beyond the other toes. The constant pressu-
Limited joint mobility
Due to the build-up of glucose in the podiatric
connective tissue, it becomes thickened and hardened, the result of which is a phenomenon
called claw toe. Due to the extra pressure with
each step, this condition can cause hyperkeratosis on the tip of the affected toe.
Hooked toe with hyperkeratosis.
re on the tip of this toe, with each step, has led
to hyperkeratosis with a central lesion.
Neuropathic complaints
A hooked big
toe.
6
Normal rolling of the foot = When walking, the foot
rolls from the heel to the metatarsal bones and kicks off
with the toes.
7
Normal skin always reacts to increased pressure and
constant chafing in the same manner: it forms localized
hyperkeratosis.
20
Some people with nerve damage in the feet
due to diabetic neuropathy do not feel any
symptoms. Others may have symptoms such as
tingling, pins and needles, burning, pain, etc. or
numbness--loss of feeling--in the hands, arms,
feet, and legs, which are more pronounced during the night. This affects the patient significantly and greatly disrupts well-being.
Special Manifestations of Diabetic
Neuropathy
Septic thrombosis
If a neuropathic lesion forms under the head
of the first os metatarsale8, bacteria can make
their way in to the soft tissue and spread until
they reach the digital artery of the big toe. Infections in this region can lead to a thrombo-
sis which blocks the artery. As a result, the surrounding tissue cannot be adequately supplied
with oxygen, and it becomes necrotic. The toe
blackens, even though the blood supply to the
rest of the foot is normal.
Septic thrombosis, with subsequent tissue necrosis, is caused by diabetic neuropathy. If the
8
Os metatarsale = metatarsal bone
▶▶Diabetic foot syndrome: from hyperkeratosis to ulcers
1. Keratosis develops at the location on the
sole of the foot that is exposed to excess
pressure. A callus is formed.
2. The callus presses into the sensitive connective tissue underneath like a small
stone and causes a haemorrhage.
to the connective tissue. The callus opens
up, forming an ulcer.
4. The bacteria can enter the deep lying tissue via the lesion, resulting in ostitis that
can involve the joint.
3. The hyperkeratosis becomes brittle and
splits. Bacteria are able to penetrate in-
1. A callus is formed
2. Subcutaneous haemorrhaging
3. Ulceration of the skin
4. Deep infection with osteomyelitis
Illustration of ulcer formation due to excess pressure.
21
▶▶Stages of septic thrombosis
22
Photo 1: The patient, by wearing shoes that
were too small, contracted a lesion on the medial side of the left 2nd toe.
Photo 2: The infection spreads until it reaches
the toe’s digital artery. Necrosis of the tissue results, leaving the bone exposed.
Photo 3: The ischaemic tissue mummifies; the
toe is unsalvable.
Photo 4: Situation following resection of the 2nd
toe. In the presence of good arterial perfusion,
the amputation bed heals flawlessly.
background of such a condition is not considered
carefully enough, it may be mistakenly seen as
an indication for too high an amputation, as
the arterial perfusion is otherwise quite normal.
▶▶Diabetic neuropathic osteoarthropathy (DNOAP)
Diabetic neuropathic osteoarthropathy
(DNOAP) or Charcot Joint Disease
DNOAP is a non-bacterial inflammatory condition located in the vicinity of the tarsal bone and
the surrounding soft tissue. The affected foot
swells and becomes considerably over-heated.
This condition is not usually accompanied by a
cutaneous wound. Unless the foot is disencumbered, microfractures in the bone can result,
leading to a permanently and fully deformed
arch of the foot.
Treating acute DNOAP
The patient was suffering from painful swelling and overheating of the right foot. Lymph
drainage was carried out to alleviate the lymphoedema. The patient continued to burden
the right foot. After a period of six weeks,
the arch of the foot had considerably altered.
The affected foot must be placed in a lowerleg orthesis until the inflammation has completely subsided.
The clinical picture of DNOAP is unfamiliar to
many doctors and is thus falsely treated--even to
the point of recommending amputation.
The right arch of the foot had completely
flattened.
Arterial insufficiency
Orthesis of the
lower leg.
Patients with diabetes tend to develop clogging
of the arteries in the lower leg, reducing the
blood flow in that area. A typical example of the
symptoms of a severe case is a condition named
Claudicatio intermittens--otherwise known as
the window-shopping-disease.
23
▶▶Arterial insufficiency
In the presence of arterial insufficiency, the visible lesion on the surface of the skin often represents
just the ’tip of the iceberg‘.
The regions suffering from lack of blood supply
(mainly the toes and heels) are particularly vulnerable to pressure, whereby lesions can appear
at the slightest injury, which are difficult to heal.
However, these particular wounds can only heal
when the blood supply in the surrounding area
is enhanced. Hence, local treatment for this condition is pointless.
As these ischaemic ulcerations usually start very small, their severity is often underestimated.
▶▶Hyperkeratosis
Hyperkeratosis on the outer side of the little
toe (Os metatarsale 5).
24
After debriding the surface of the callus, one can
see that the underlying lesion has reached as far
as the bone.
Conclusion
In the treatment of diabetic foot syndrome, the
underlying cause of the disease should be clarified before initiating any therapeutical measures. First and foremost, the presence of arterial insufficiency must either be conclusively confirmed or ruled out.
The type of therapy will depend upon this important diagnostic step.
Differentiating between diabetic neuropathy and arterial insufficiency
The main feature of the presence of both diabetic neuropathy and arterial insufficiency is the
absence of sensation. Due to the nerve damage,
even a severe ischaemic wound causes no pain
in the affected muscle. As a result, the severity
of the arterial insufficiency is easily overlooked.
The discernment between diabetic neuropathy and arterial insufficiency, which often needs to be done
using technical diagnostics, is of utmost importance.
skin
Further factors that exacerbate diabetic foot syndrome are:
–– chronic venous insufficiency and varicose veins
–– lymphoedema
–– visual impairment
–– neurological disorders such as paresis of foot
elevation following apoplexy
Treating a diabetic neuropathic foot lesion involves:
–– complete pressure relief for the affected area
–– systemic antibiotics (depending on the size of
the lesion)
–– optimization of blood glucose levels
Treatment of arterially insufficient lesions
First:
–– carry out interventional measures to correct
the arterial insufficiency
Then:
–– completely relieve the affected area of pressure
–– administer systemic antibiotics (depending on
the size of the lesion)
–– optimize blood glucose levels
Neuropathy
PAD
dry, warm, pink, varicosis even at 30°C
and raised, with no change of colour
atrophic, thin, cool, pallid, and relief when
forefoot is raised
tissue
oedema frequently detectable
oedema rare
hyperkeratosis
pronounced on pressure points, splits on
the heels
slowed growth, sand-papery hyperkeratosis
nails
mycosis, subungual bleeding
thickened, hyperonychia
toes
clawed/hammer toes, corns
no hair, pallid, acral lesions
arch of the foot
atrophy of the Mm. interossei
general atrophy
sole
hyperkeratosis, rhagades, pressure ulcers
skin removable in folds
How to differentiate between neuropathy and peripheral arterial occlusive disease.
25
In planning for a stage-oriented mode of treatment, the size of the lesion must be accurately determined. The Wagner-Armstrong wound
classification method is designed for this purpose (see Table).
The most common cause of foot lesions is the wearing of shoes that are too small.
Wagner-Stage ▶
0
1
2
A
pre- or postulcerated
foot
shallow
wound
wound
reaches
tendon or
capsule
B
w/ infection
w/ infection
w/ infection
C
w/ ischaemia w/ ischaemia w/ ischaemia w/ ischaemia w/ ischaemia w/ ischaemia
Armstrong-
Stage ▼
D
infection
and
ischaemia
infection
and
ischaemia
infection
and
ischaemia
3
4
5
deep wound necrosis on
reaching bo- parts of foot
ne and joint
necrosis on
entire foot
w/ infection
w/ infection
infection
and
ischaemia
w/ infection
infection
and
ischaemia
infection
and
ischaemia
Descriptions of the diabetic foot syndrome using the Wagner-Armstrong method of classification.
26
The Specialized Diabetes Practice
The Specialized Diabetes Practice:
Clinical Photographs
Skin Disorders in Diabetes
When treating people with the diabetic foot, I am often confronted with skin disorders not necessarily directly related to the condition. Time and again I see conditions that are not able to be deciphered with diabetological competence alone. In cases such as these, I confer with a dermatologist.
1. Patient with mycosis of the toenails
Patients with badly controlled diabetes often
suffer from mycosis of the toenails. Treatment
can only be successful when the blood glucose
is stabilized. The use of local therapeutical measures such as nail polishes containing antimycotic substances are usually ineffective.
2. Patient with mycosis on the soles of the feet
Fairly typical of mycosis of the sole is the
relatively sharply defined redness under
the foot (‘moccassin‘
disorder). Effective
treatment of this condition must include
the socks and shoes.
27
3. Ingrown toenails
The pressure of the brittle toenail in the nail
wall can cause a very painful infection of the
nail bed = panaritium.
4. Severe infection of the nail bed with protruding
granulatory tissue
Nail bed infections of the big toes on both feet.
5. Neglect
Protruding, brittle toenails can injure neighbour
ing toes.
28
6. Oedema of the lower leg: danger of injury due to tight
socks
7. Skin disorders with chronic venous insufficiency
On the right lower leg of this patient, one can
see a severe trophic skin disorder with postthrombotic syndrome. The skin is so fragile that
even the constant contact with the inside of the
trousers can cause a lesion to appear on the surface of the skin.
8. Patient with Klippel-Trenaunay Syndrome
Klippel-Trenaunay Syndrome is a
congenital abnormality affecting
the soft tissues and blood vessels.
Here, the patient’s left lower leg
and foot is seriously afflicted. She
eventually decided to have the lower limb amputated.
29
9. Varicose Ulcer Cruris
Due to venous insufficiency, the skin and the underlying tissue become frail and liable to develop deep chronic wounds.
10. Plantar Warts
A plantar wart on the ball of the foot.
30
A large plantar wart under the heel following
many attempts at healing.
11. Petechiae skin purpura
Petechiae describes round spots that appear on
the skin as a result of subcutaneous bleeding.
This picture illustrates a case on the lower leg.
The abdomen of the same patient.
Explanation: This patient was treated with antibiotics because of diabetic foot. As a result, bacterial colitis developed manifesting as petechiae.
12. Foreign body following surgery
On the medial side of the left head of the 1st
metatarsal bone of this patient, a lesion developed containing a hard object.
The object was removed with tweezers. Years
before, the patient had undergone surgery on
the left foot. The surgeon had implanted an antibiotic chain. With time, one of the links of this
chain had made its way to the surface.
31
13. Venostatis dermatosis on the lower leg
14. Widespread hyperkeratosis on the sole
This patient was operated on the forefoot,
after he wore shoes
whose inlays were no
longer effective.
32
Complications
Complications
with Diabetes Therapy
Adverse Reactions to
Medication
Oral antidiabetics rarely trigger allergic reactions. The reaction shown here involved
maculopapular efflorescence which spread
over the whole body, especially on the trunk.
Reactions such as these appear somewhat like
measles or chickenpox and are usually accompanied by a general feeling of ill-being. The patient recovers as soon as the medication in question is stopped.
Sulfonylureas (not to be confused with urea)
tend to be associated with increased photosensitivity. Hence, patients taking such medications
are more vulnerable to getting burnt when out
in the sun. This is particularly true as people with
diabetes tend to prefer sugar substitutes, such
as cyclamate or aspartame, which also raise the
skin’s sensitivity to light.
Insulin Allergy
There are two different types of insulin allergy. One involves a local allergic reaction,
and the other involves a generalized reaction which takes the form of exanthema (sudden rash), or other unspecific symptoms such
as itching, wheals, or erythema. Local infections involve redness, wheals and/or nodules that appear around the injection site.
Whether or not one is at risk for developing
Adverse reaction to medication.
33
Complications
an allergy is usually genetic. Patients known
to have an allergy to penicillin are statistically more likely to develop an allergy to insulin.
Generalized allergic reactions are rare indeed.
This usually manifests as exanthema, but urticaria
with angiooedema has also been known to occur.
If you have cause to suspect the development
of an insulin allergy, an allergologist should be
consulted to carry out a conclusive diagnosis.
34
Insulin Lipodystrophy
Insulin lipodystrophy.
Insulin lipodystrophy is a rare side effect of insulin administration, whereby the skin and the underlying tissue thins out or granulates at the injection site. This condition affects mostly women
and children, and usually appears six months to
two years after commencement of therapy. Fortunately, this anomaly tends to disappear by itself.
In any case, the injection site should be changed.
Local complications such as this tend to appear
more often with animal insulin of sub-quality.
However, due to the modern-day usage of genetically engineered insulins, this problem has
lessened considerably.
Skin Care
Skin Care and Diabetes
Approximately 80% of people with diabetes suffer from some kind of skin problem as a consequence of high blood sugar levels. Typical
symptoms are extreme dryness (xerosis, xerodermatitis), calluses, pressure ulcers and cracks
on the feet, itchiness, skin infections and sores.
The sweat and subaceous glands often fail to
work properly, leaving the skin without an adequate supply of oil and moisture. Thus, the skin
rapidly becomes rough and scaly. This problem
is most visible on the legs and the feet, and is
usually accompanied by itching. Dry skin reacts to external chemical and physical hazards more easily than normal skin. Bacteria,
moulds, allergens and poisons can enter the
skin more easily and cause irritations. In addition, the dry skin is exacerbated by the fact
that lack of insulin disrupts the differentiation
of the keratinocytes, damaging the skin barrier.
Diabetes therapy must, therefore, include an
appropriate skin care regimen. The purpose of
skin care products is to replenish the skin’s moisture and fat content, as well as to create a protective layer against the outside environment.
Extra-cellular lipids in
the keratinous layer
Corneocyte
Living Epidermis
Fig.1: Schematic diagram of the skin barrier.
Transepidermal Water
Loss (TEWL)
Transpiration
Fig. 1a: Transepidermal Water Loss (TEWL) is a
method for assessing the barrier function by measuring the skin’s rate of transpiration.
A Defensive Shield
The most important function of the skin is to
create an effective barrier between the organism and the environment. The outer layer (epidermis) forms a physical, chemical/biological and
an adaptive immunological line of defence. The
physical barrier function is carried out by the
horny layer of the skin (Stratum corneum), the
outermost layer of the epidermis, made up of a
physical and molecular weaving of the cells (corneocytes) as well as the double layered sheet of
stratum-corneum lipids (see Fig. 1).
A method of assessing the health of the outer
layer of the skin and the effectiveness skin care
products have had, is the measurement of trans
epidermal water loss (TEWL). Here, the evaporation of the water that passes through the epidermis is measured on a particular area of the
35
Skin Care
Liquid
O/W-Emulsion
W/O-Emulsion
Oil
Water
Alcohol,
water, aqueous solutions
Hydrogel
Lotion
Cream
CreSa
Ointment
Fatty
cream
Suspension
(Lotion)
Powder
Pastes
Talcum,
Zinc oxide
Fats, Oils,
Waxes
type of product used, this can inflict further
damage to the skin barrier.
Fig. 2: Triangle illustrating the various combinations
of bases.
Most products used in the care of dry skin are
manufactured as liquid or spreadable emulsions.
These can be divided up into four different bases (Fig. 2a):
skin over a particular time. The rate of TEWL
increases in proportion to the level of damage
to the cutaneous barrier. Hence, a reduction in
TEWL signifies a reconstitution (Fig. 1a).
•
•
•
•
Hydrolotions: liquid oil-in-water emulsions
Lipolotions: liquid water-in-oil emulsions
Creams: spreadable oil-in-water emulsions
Fatty creams: spreadable water-in-oil emulsions
The ways in which these traditional formulas affect the skin is summarized in Table 1.
Systematics of External Preparations
Caring for dry skin can be done using different
kinds of external formulas. A systematic categorization can be taken from the phase-triangle
used in dermatology to illustrate the effect different types of formulas have on the skin and
how they are absorbed (Fig. 2).
In order to keep the lotions and creams stable,
an emulsifier is added that not only lengthens
the shelf-life of the product but also improves
its texture. These emulsifiers belong, in their
physical attributes and chemical behaviour, to
the class of surfactants. They are built like an
The type of formula used depends on the
severity of the dermatosis, and the severity of the damage to the skin. A general rule of thumb: wet-on-wet and fat-on-dry.
If this guideline is overlooked, and the wrong
type of formulation
Oil
Fig. 2a: The two different kinds of emulsions: oil-inwater to form lotions and creams, and water-in-oil
to form lipolotions, fatty creams and ointments.
Fat
Pasten
Water
cooling
greasy
hydrative
occlusive
rinses off
+
+
+(+)
-
+
lipolotions
-
++(+)
++
++
-
creams
+
+
+(+)
+
+
thick creams/ointments
-
++(+)
++
++
-(-)
hydrolotions
Table 1: Skin care products and their intended effects.
36
Skin Care
(b)
(a)
Fig. 3: Lipid structure of the skin barrier; (a) proper lamellar formation, (b) structural disorder and emulsification through hydrophilic surfactants.
amphiphile with a hyprophile and lipophile molecular structure, and form bonds, for example,
micelles or lamellar liquid crystals (Fig. 4). Due
to their surface-active properties, emulsifiers interact in many different ways with the skin barrier, especially with the lipids in the horny layer.
In particular, the water-soluble, hydrophile surfactants, responsible for stabilizing oil-in-water
bases, can actually emulsify the lipids on the skin
and adversely affect its barrier function when
applied in large amounts (Fig. 3).
Classifying skin care products merely by their
water and lipid content is, however, too simple.
Only by knowing the types of emulsifiers contained in them can you ascertain whether they
are based on a water-in-oil or an oil-in-water
formular. For instance, a base with 60% water
and comparable fat content can, with a hydrophilic emulsifier, become an oil-in-water formula, whereas if a lipophilic emulsifier is used, it
becomes a more easily spreadable water-in-oil
cream. In other words, bases with around the
same content of water and oil can, depending
on the type of emulsifier used, have a profound-
ly different effect on dry skin, even if they share
similar consistencies.
Mousses
Mousses contain gas in a continuous-liquid or
semi-liquid form. Depending on how the gas is
dispersed, balls of foam or polyederfoam are
formed, within which the single bubbles of gas
are separated by microscopic lamelles (Fig. 6).
Mousses are manufactured by compressing the
liquid or semi-solid formula into a pressurized
When treatments work best
Care products work best directly after the skin has been washed. The
skin should be dried, with no water
remaining on the surface. In this way,
skin care products are easier to apply
and more easily absorbed.
37
Skin Care
container and topping it up with aerosol. Due
to this process, mousses are also named foam
aerosols, to which the foam creams also belong. The latter is made with an oil-in-water
emulsion combined with an oil-soluble aerosol. When used, the emulsion exits the container through a small valve at the top and, due to
the sudden evaporation, forms a foam. In other words, the foam is formed only on applica-
hydrophile
tion (Fig. 5). The most commonly used aerosols
in mousses are propane gas, butane and isobutane gas or, albeit very rarely, dinitrogen monoxide (laughing gas).
Larger Surface Area, Better Evaporation
The foaming action of an oil-in-water emulsion
creates a very large surface area from which vol-
lipophile
Tenside molecule
Micelle
Lamellar liquid crystal
Fig. 4: Schematic illustration of a tenside molecule, a micelle, and lamellar liquid crystal.
Water state
Water state
Oil state
Oil state
+
Aerosol
(a)
Aerosol
(b)
Fig. 5: Schematic illustration of the structure or mousse in a pressurized can before (a) and after (b) release.
38
Skin Care
pure
oil
gas
bubbles
cream lamellas
soluble
bath oil
Fig. 6: Microscopic view of mousse.
atile substances, such as water, can evaporate
much faster than from creams. When applied,
the preparation of the mousse, once it’s on the
skin, shows very little similarity to that which
was in the container prior to application. In other words, the watery solution in the can turns
into a fatty cream when applied to the skin.
This makes it easy to apply whilst keeping the
positive effects of a lipid-rich preparation once
on the skin.
Hygienically Dosed and Efficient
Apart from the cosmetic aspects, mousses have
other advantages over conventional forms of
application such as lotions and creams. They
can be hygienically and accurately dosed, and
dispersing
bath oil
Fig. 7: Types of bath oils in comparison.
are protected from contamination. In this way,
the use of preservatives can often be spared.
The air-tight aerosol container, impermeable
to light, halts the effects of oxidation and protects light-sensitive substances. A foam can be
applied evenly without having to touch the affected area, and is quickly absorbed. Thus, due
to their ease of application, foams are suitable
for wounds or infected skin, for babies and
children, and difficult-to-access areas such as
between the toes.
Bath Oils
Fig. 8: Pure oil in water produces an oily bath with
fat globules that are unevenly dispersed onto the
skin.
Also part of the skin care regime is the use
of bath oils, which can be classified into two
groups: dispersing bath oils and soluble bath
oils (Figs. 7 and 8). Bath oils contain lipids (e.g.,
soy oil, olive oil, almond oil, paraffin) that remain as a thin film on the skin after you get out
of the bath. The most effective substances for
this purpose are dispersing bath oils. These differ from the soluble bath oils in that they contain very little or no emulsifying agents. The oil
floats on the top of the bath, and clings to the
skin as you get out (as well as on the bath tub).
However, this fatty film may smear any clothing
you put on afterwards. After such a bath, you
39
Skin Care
should not dry your skin too vigorously, otherwise the beneficial effect is lost.
Skin Care that ‘Breathes’
The skin is said to ‘breathe’ because it discharges vapour to the environment. If this process
is hindered, an ‘occlusion’ occurs, which leads
to over-heating. A complete occlusion, for instance, with a thick smear of petroleum jelly,
causes a disruption in the renewal and development of the cells in the epidermis, as well as
their metabolism. This damages the horny layer, that is, the skin barrier. When cosmetics are
applied, the occlusive effect is only temporary,
the length of which depends upon:
• the type of base used (pure oils, pure fats, water-in-oil emulsions, oil-in-water emulsions)
• the amount and type of lipids used
• additives, such as dispersants or emulsifiers
• the amount of product applied and whether
is is rubbed in
A partial occlusion can be effective when using
skin care products, as this increases the moisture level of the skin.
Skin care which allows your skin to breathe combines effective care and enables water vapour
to escape at the same time. A measurement of
Oily baths used after showering
Oily baths are part of the skin care
regimen, and should be used only after cleaning the skin. Therefore, bath
oils may also be applied to the skin after showering and then briefly rinsed
off. Afterwards the skin should not
be dried too vigorously so that the oil
does not rub off.
40
Target parameter
Test method
barrier function
transepidermal water loss
(TEWL)
hydration
of the skin
corneometry
lipid content
sebumetry
cutaneous pH
value
pH-metry
skin elasticity
cutometry
epidermal
structure
profilometry
cutaneous
structure
sonography, confocal laser scanning microscopy,
confocal raman microscopy
Table 2: Usual methods for proving the effectiveness of skin care products.
the TEWL under controlled conditions is the only
way to conclusively assess how occlusive a product really is. A test such as this will show exactly how much water vapour is lost shortly after
applying a product.
Additional Ingredients in Skin Care
Products
To enhance the effect of skin care products for people with diabetes, certain substances are added in the manufacturing process to absorb water (humectants) or to enrich the skin’s natural lipid film (emollients).
In addition, certain ingredients are added to
creams for the feet to soften hard skin and
calluses and to prevent invasions of bacteria.
The most significant of these types of products is urea. This substance increases the
skin’s ability to hold moisture and, in higher concentrations (over 10%), softens and
reduces the hard skin layers. Thus, urea
has a keratoplastic and keratolytic effect.
Other ingredients used in cosmetic products for dry skin are glycerine, vitamin E,
panthenol, lactic acid, sodium lactate, betulinic acid, N-palmitoylethanolamine, hyaluronic acid and St John’s wort extract.
Skin Care
Lipids of various chemical classes such as triglycerides (vegetable or semisynthetic oils), solid and
liquid wax esters (cetyl palmitate or isopropyl
palmitate), fatty alcohols, fatty acids such as
stearic acid, sterols (lanolin) and phytosterols,
and partial glycerides (glycerol monostearate)
are just some of the countless synthetic and natural products used in the making of emollients.
Ingredients that are used as antiseptics are octenidine hydrochloride, polyhexanide and microsilver.
The dry skin of a diabetic requires
special attention. Suitable products
need to impart sufficient fat and
moisture to the skin. The various galenic forms of skin care products significantly influence their effectiveness and ease of application. Their
recipes on paper only give a hint as
to how they differ from each other.
Conclusive data can only be collected
in controlled studies.
41
Skin Care
Effectiveness and Tolerability of Skin
Care Products
Just the recipe of a skin care product cannot
determine the product’s effectiveness and tolerability from the outset. All this – the product’s moisture and fat-containing ability, as
well as its barrier effect – has to be tested invivo under controlled conditions. The basic
method used here is to compare somebody
with treated skin to a control person with untreated dry skin (intraindividual comparison).
The objective assessment is usually done by
biophysical measurement along with spectroscopic and microscopic examination (Tab. 2).
Not only the effectiveness of the product,
but also its tolerability (irritation potential,
sensitization potential, comedogenic effect)
needs to be evaluated in-vivo on test persons or in-vitro under laboratory conditions.
Detailed guidelines on these themes can be
found, for example, in the Society of Dermopharmacy’s ‘Dermocosmetics for Cleansing and
Caring for Dry Skin’ (www.gd-online.de).
Author:
Prof. Dr. Rolf Daniels
Eberhard-Karls-Universität Tübingen
Auf der Morgenstelle 8, 72076 Tübingen
42
Ingredients
Useful Facts
on Cosmetic Ingredients
In the daily work of dermatologists and podiatrists the question arises again and again as to
what’s in cosmetic and skin care products. “What
is the most suitable product for my skin type?”
“Which creams do you recommend?” or “What
do you think of such and such a product?”
Reference for the clinic
We would like to present an overview of the
most important ingredients of skin care products
and their effects. This may be used as a quick reference to be of assistance in the clinic.
Principally, it is important to know that the words
“dermatologically tested” is not protected. This
means, there exists no standardized criteria of
quality to control who carries out the dermatological tests or how they are done. The words
“suitable for diabetics” doesn’t necessarily guarantee that product is indeed suitable for diabetics. This is why it is important to pay attention to
the safety and benefit studies – something that
can always be depended upon for pharmaceutical products.
In the European Union, all contents of skin care
products must be declared on the packaging, so
that all ingredients of the product can be identified.
43
Ingredients
Alcohol
Synonyms: ethyl alcohol, ethanol
Origin/Production: Alcohols are organic hydrocarbon compounds whose hydrogen atoms are
displaced by hydroxyl groups. They are categorized into one-, two-, three- or polyhydric alcohols, depending on the number of hydroxyl
groups, and primary, secondary and tertiary alcohols, depending on the connecting area, where
the hydroxyl group binds to the hydrocarbon.
The most important alcohols are, among others, ethanol, glycerine, isopropanol, propylene
glycol, and sorbitol.
Properties/Applications: Alcohol is used in cosmetics as a disinfectant, preservative, fragrance,
and solvent. If used in high concentrations, it
can have a drying effect on the skin.
Allantoin
Synonym: Allantoin
Origin/Production: Allantoin is an endproduct
of the oxidation of uric acid by purine catabolism. It is present in most mammals as well as in
plants (wheat germ, comfrey root, the bark of
the horse chestnut tree).
Properties/Applications: Allantoin, in the form
of clear, shiny leaflets or as a crystal powder, is
used in the manufacturing of skin care products
(clarifying lotions, moisturizers, sun care products, lip balms) as well as in pharmaceutical products used for dry skin. It is fragrance free, tasteless, fat-soluble, and anti-irritant. It is soothing,
anti-inflammatory, promotes cell proliferation,
keratolytic, smoothes rough skin, and increases
the moisture content of the epidermis.
Aloe Barbadensis Extract
Synonyms: aloe vera
Origin/Production: Aloe vera is the name given
to a species of cactus from the lily family that
thrives in the desert (over 200 types), with thick
fleshy leaves. Only the gel-like flesh of the leaves
44
is used in cosmetic products. It is pressed, and
the resulting slime extracted, filtered, and pasteurized. The gel is not only rich in minerals, but
also contains numerous other substances such
as enzymes, amino acids, sterols, vitamins, and
mucopolysaccharides.
Properties/Applications: Aloe vera has healing
properties, imparts moisture, reduces pain, reduces inflammation, and cools. It is even said
to protect against UV rays to a certain extent.
Arnica Montana Extract
Synonyms: leopard’s bane, wolf’s bane, mountain tobacco, mountain arnica, arnica , arnica
fulgens, arnica sororia.
Origin/Production: Arnica is a medicinal plant
belonging to the daisy family. The petals contain
a highly poisonous essential oil. It also produces bitters and tannins as well as secondary plant
products (carotinoids, flavonoids). The essential
oil of the plant is extracted from the flowers and
the roots via steam distillation.
Properties/Applications: The essential oil is
used as fragrance in perfumes, or as a tincture
in creams for the skin and feet. The substance
is considered to be an irritant.*
Benzoic Acid/Sodium
Benzoate
Synonyms: benzenecarboxylic acid, benzeneformic acid
Origin/Production: Benzoic acid is found in berries, and in an Asian gum resin, but is now mostly manufactured synthetically.
Properties/Applications: The weak acid is used,
due to its antiseptic and antimycotic qualities,
as a food preservative.
Biotin
Synonyms: vitamin B7, vitamin H
Origin/Production: Biotin is a natural and commonly occuring water-soluble vitamin. In hu-
Ingredients
mans, it is responsible for, among other things,
the maintenance of healthy skin, hair and nails.
Clinical manifestations of biotin deficiency are
evident in the form of skin eruptions, dry skin,
hair loss, brittle nails, and irritability.
Properties/Applications: Due to its nurturing and
antiseborrheic qualities, it is used in the care of
hair and nails.
Butyrospermum Parkii Butter
Synonyms: shea tree butter, karité butter
Origin/Production: The oil is extracted from the
kernels of the shea fruit by cold pressing.
Properties/Applications: Due to its caring, smoothing and moisturizing qualities, shea butter is used
in cosmetics as an emollient. It is also used as a skin
care product, especially for sun damage.
Cera Alba
Synonyms: beeswax
Origin/Production: Beeswax is excreted by bees
to build honey cone.
Properties/Applications: Beeswax is produced as
an ingredient in skin care products in the form
of Cera flava (yellow wax) and Cera alba (white
wax). It cares and protects sensitive skin. It is
mainly used in natural cosmetics.
and plays a role in the metabolism of all living things. It is extracted biotechnologically
from the juice of citrus fruits. Once extracted,
it forms clear and odourless crystals, or a sour
crystalline powder.
Properties/Applications: Citric acid has bleaching properties. It acts as an astringent, and positively influences the rate of cell regeneration.
Thus, it is used as a buffer compound. It is also
used in astringents and, due to its ability to chelate metals, in soaps. It may contain residues of
allergenic material.*
Dimethicone
Synonyms: polydimethylsiloxane (PDMS), silicone oil
Origin/Production: This silicone oil is a synthetic
mix of fully methylated, linial siloxane polymers.
Properties/Applications: It is anti-allergenic and
makes the skin feel smooth. It is used as an emollient and anti-foaming agent. Not being very
biodegradable, its use is environmentally questionable. Natural alternatives to this product are
almond oil, avocado oil, and fats.*
Glycerin
Synonyms: cetostearyl alcohol
Origin/Production: Cetearyl alcohol is a mixture
of cetyl and stearyl alcohols.
Properties/Applications: Cetearyl alcohol imparts
a silky, emollient feel to the skin. It is used as an
emulsion, and as an opacifying and viscosity-increasing agent.
Synonyms: glycerol, glycerine
Origin/Production: Glycerin is the simplest trivalent alcohol present in, depending on its fatty acid compound, vegetable and animal fat.
It can be synthetically produced or extracted
from plants. It is also a by-product in the making of soap.
Properties/Applications: Due to its hygroscopic
properties, it is used as a humectant in moisturizers. In high concentrations of over 30%, however, it dries and irritates the skin.
Citric Acid
Hyaluronic Acid
Synonyms: hydrogen citrate
Origin/Production: This organic acid is the
most commonly occuring in the plant world,
Synonyms: hyaluronan, hyaluronate
Origin/Production: Hyaluronic acid is a highly
viscous, naturally occuring mucopolysaccharide
Cetearyl Alcohol
45
Ingredients
found in the connective and lubricating tissues of
the body. It is made up of glucuron acid and acetylchondrosamine or acetylglucosamine. Along
with collagen, it makes up a significant part of
the synovial fluid, that mobilizes the water-soluble substances between the cells. As one gets
older, the amount of naturally occuring hyaluronic acid lessens, thus the skin loses its ability
to hold moisture and its elasticity.
Properties/Applications: Due to its ability to
hold moisture, hyaluronic acid can transport
water to matrix of the connective tissue. It also builds a film, permeable to air, protecting
the stratum corneum from drying out. Hyaluronic acid is, therefore, used as an ingredient
in moisturizers.
Lanolin
Synonyms: wool wax, lanoline, adeps lanae, cera lanae
Origin/Production: Lanolin is produced in the sebaceous glands in the skin of the sheep, and extracted from its wool after being shorn. It contains a mixture of wool wax (65%), water (20%),
and mineral or vegetable oil such as paraffin
(15%).
Properties/Applications: Due to its softening and
moisturizing properties, this substance is widely
used in pharmaceutical and cosmetic products,
for instance, as a base for creams and ointments.
In addition, it is used as an antistatic, an emollient, an emulsifier, a skin care product, and a
surfactant. As lanolin can contain residues of
pesticides, products containing lanolin used to
have to state “contains lanolin” to warn consumers against a possible allergic reaction. Why
this warning is no longer obligatory is unclear.*
Myroxylon Pereirae Resin
fragrance or active ingredient in cosmetic products. It contains, however, allergic potential.*
Oenothera Biennis Oil
Synonyms: primrose oil, evening primrose oil
Origin/Production: The oil of the seeds of the
primrose flower contains unsaturated fatty a
cids
(linoleic, linolenic, oleic acids). The primrose
grows in north America, Europe, Turkey, New
Zealand and Australia.
Properties/Applications: It positively affects the
epidermal barrier function in dermatitis and is
used to moisturize dry skin. Primrose oil is soothing to the skin.
Olea Europaea Oil
Synonyms: olive oil
Origin/Production: Olive oil, a yellowish-green
oil, is obtained from the little fruits of the olive
tree by cold pressing. The olive tree is native to
the mediterranean regions. Olive oils is a rich
source of unsaturated fatty acids (oleic, palmitic and linoleic acids), vitamins A and E, as well
as traces of minerals.
Properties/Applications: Olive oil is smoothing
to the skin. It acts as a lubricant and moisturizer.
Panthenol
Synonyms: D-panthenol, provitamin B5
Origin/Production: Panthenol is the precursor
to pantothenic acid, the substance that is transformed enzymatically into the vitamin D-pantothenic acid (vitamin B5). It is present in all living cells.
Properties/Applications: Panthenol has soothing
and anti-inflammatory properties. It smoothes
the skin, imparts moisture, and supports the
wound-healing process.
Synonyms: Peru balsam, balsamum peruvianum
Origin/Production: Peru balsam is a substance in
plants extracted by smoking the bark of trees.
Properties/Applications: Peru balsam is used as a
46
Ingredients
Parabens
Origin/Production: Parabens are a group of para-hydroxybenzoic acid esters such as methyl,
ethyl, butyl, and propyl parabens.
Properties/Applications: Parabens are used as
preservatives, as they hinder the development
of microorganisms (especially yeasts and moulds)
in the manufacturing of cosmetics.
compression from the kernels of the nuts of the
sweet almond tree, native to Asia, north Africa, Israel, California and the mediterranean regions. The light yellow oil is almost odourless.
It contains oleic and linoleic acids, but quickly
becomes rancid.
Properties/Applications: Almond oil replenishes
the skin’s moisture and helps it in healing. It is
used as an emollient and as a skin care product.
Persea Gratissima Oil
Retinol
Synonyms: avocado oil, alligator pear oil
Origin/Production: The edible fat of the dark
green to brownish red avocado pear, originating in middle and south America. The oil is extracted from the flesh of the fruit through cold
compression. The fruit contains high levels of antioxidants (vitamins A and E), vitamin D, B6, potassium, magnesium, phytosterols and lecithin.
It is rich in unsaturated fats.
Properties/Applications: Avocado oil is used in
cosmetics as an emollient. Due to its replenishing, healing, softening and hydrating effects, avocado oil is used in products for dry, scaly and
mature skin. Due to its high content of antioxidants, it takes longer to go rancid.
Synonyms: vitamin A
Origin/Production: A fat-soluble, essential vitamin. The provitamin, betacarotine, is converted
to vitamin A in the human body. Products containing retinol must be protected with antioxidants and light.
Properties/Applications: Retinol replenishes the
skin’s moisture, and raises the mitosis activity of
the cells and promotes cell proliferation.
Propylene Glycol
Synonyms: alpha-propylene glycol, methylethylene glycol
Origin/Production: A clear, odourless liquid with
a sweet taste, and is synthetically produced. It
belongs to the class of alcohols that are derived
from the alkanes.
Properties/Applications: Propylene glycol is hygroscopic and is, therefore, used as a humectant in moisturizers and as a skin conditioner. It
is also used as a solvent and viscosity controller.
Prunus Amygdalus Dulcis Oil
Synonyms: almond oil
Origin/Production: The oil is extracted by cold
Silver
Synonyms: microsilver
Origin/Production: Elemental silver, as well as
its alloys, are used in products. The active substances, however, are its ions.
Properties/Applications: Silver is used as an antimicrobial substance in skin care products.
Saccharide Isomerate
Synonyms: PentavitinTM
Origin/Production: Saccharide isomerate is an
acqueous solution of carbohydrates present in
the epidermis. It is extracted from natural sugar.
Properties/Applications: It improves the moisture-holding ability of the Stratum corneum. It
binds with keratin so that the moisturizing particles on the surface of the skin cannot easily be
washed away, neither with soaps nor with water. Thus, its moisturizing benefits remain over a
long period of time. For this reason, it is known
as the ‘moisture magnet’.
47
Ingredients
Simmondsia Chinensis Oil
Synonyms: jojoba oil
Origin/Production: Jojoba oil is extracted using
cold compression from the seeds of the Simmondsia chinensis plant, a shrub native to the coastal
desert areas of America. It is a light yellow, liquidy wax containing erucic, oleic and gadoleic
acids. It resembles the fat mix in human skin.
Properties/Applications: Jojoba oil is easily absorbed into the skin, hence it is used in products for all skin types, but mainly for dry skin.
Jojoba oil is used as an emollient and feels very
smooth on the skin. Apart from this, it has a very
long shelf-life.
Sodium Chloride
Synonyms: salt
Origin/Production: Salt is obtained from salt reserves, brine, salt lakes, and sea water, by mining rock salt. It is composed of chloride and sodium ions.
Properties/Applications: Sodium Chloride is used
to control viscosity and as a swelling agent.
Sorbitol
Synonyms: glucitol, sugar alcohol
Origin/Production: Sorbitol is a white, crystalline, weakly hygroscopic, odourless, sweet-tasting powder present in many fruits (berries, cherries, apples, plums). It can also be manufactured
from glucose with the help of certain enzymes.
Properties/Applications: Sorbitol is used as a humectant and thickener in moisturizers.
Stearic Acid
Synonyms: octadecanoic acid
Origin/Production: Stearic acid is saturated fatty
acid found in plant and animal fats. It is white,
solid, waxy and odourless.
Properties/Applications: In cosmetics, stearic acid
48
is used as a cleanser and moisturizer, as emulsifier and stabilizer.
Tocopherol/Tocopheryl
Acetate
Synonyms: vitamin E, vitamin E acetate
Origin/Production: Vitamin E consists of all the
tocopherol and tocotrienol derivatives, whose biological activity qualitatively belongs to the RRRalpha-tocopheral (or ddd-gamma-tocopherol)
stereoisomers. Vegetable oils, such as wheatgerm
oil and sunflower oil, as well as grains, seeds and
nuts, contain considerable amounts of fat soluble
vitamins. Vitamin E acetate is a more stable form
of tocopherol. Tocopherols are obtained by chemical manufacturing, or through natural means.
Properties/Applications: Tocopherol moisturizes
the skin. Tocopherols are used in combination
with antioxidants and free radical scavengers.
Urea
Synonyms: carbamide
Origin/Production: Urea is a naturally occuring,
non-allergenic substance involved in the meta
bolism of amino acids. Nowadays, urea is synthetically manufactured.
Properties/Applications: Urea is a natural water
retainer. It belongs to one of the natural moisturizing factors (NMF) of the keratic outer skin
layer (Stratum corneum), enhancing its moisturecontaining ability. Depending on the concentration, urea not only rehydrates the skin, it can also be used as a debriding agent, an anti-irritant,
or as an antiseptic.
Vitis Vinifera Seed Oil
Synonyms: grape seed oil
Origin/Production: Grape seed oil is extracted
from the pips of grapes that grow in the clima
tically temperate subtropical regions. Above all,
it contains linoleic and oleic acids, as well as vitamin E.
Ingredients
Properties/Applications: Grape seed oil nourishes
the skin, aids in skin repair, and is also used as an
emollient and antioxidant in skin care products.
Zinc Oxide
Synonyms: zinc white, calamine
Origin/Production: A white mineral powder.
Properties/Applications: Zinc oxide is used in topical healing products. It has astringent and drying effects. It is also used as a swelling agent as
well as a UV-filter.
* As determined, among other sources, by the ÖKO-TESTKosmetik-Liste.
49
▶▶The Diabetic Foot Syndrome
The clinical guidelines entitled ‘The Diabetic Foot Syndrome’ appeared at the
end of 2008. In this publication, the authors, Dr. Martin Lederle, Dr. Joachim
Kersken and Prof. Maximilian Spraul,
examine thoroughly the Type 2 Diabetes National Guidelines. In just under 30
pages, the reader can find everything
that is crucial in the treatment of the
diabetic foot.
If interested, please contact:
neubourg skin care
Mergenthalerstr. 40
48268 Greven
Telefon: 0 25 71 / 57 40 - 0
Telefax: 0 25 71 / 57 40 - 1 00
50
Addresses
Useful Addresses in Germany
Associations and Institutions
ABDA – Bundesvereinigung Deutscher
Apothekerverbände
Jägerstr. 49/50
10117 Berlin
Tel.: 0 30 / 4 00 04 - 0
Fax: 0 30 / 4 00 04 - 5 98
E-Mail: pressestelle@abda.aponet.de
Internet: www.abda.de
Bundesverband Niedergelassener
Diabetologen e.V. (BVND)
Geschäftsstelle
c/o med info GmbH
Hainenbachstr. 25
89522 Heidenheim
Tel.: 0 73 21 / 94 99 19
Fax: 0 73 21 / 94 98 19
E-Mail: mail@bvnd.de
Internet: www.bvnd.de
Berufsverband Deutscher Diabetologen e.V.
(BDD)
Waldstraße 6 A
14548 Schwielowsee-Caputh
Tel.: 0 33 / 2 09 22 99 - 70
Fax: 0 33 / 2 09 22 99 - 75
E-Mail: buero@bvdk-bdd.de
Internet: www.bvdk-ev.de
Deutsche Diabetes-Gesellschaft (DDG)
Geschäftsstelle der DDG
Reinhardtstraße 31
10117 Berlin
Tel.: 030 / 311 6937 - 0
Fax: 030 / 311 693720
E-Mail: info@ddg.info
Internet: www.ddg.info
Bund Diabetischer Kinder u. Jugendlicher e.V.
(BDKJ)
Hahnbrunner Str. 46
67659 Kaiserslautern
Tel.: 06 31 / 7 64 88
Fax: 06 31 / 9 72 22
E-Mail: diabeteskl@aol.com
AG Fuß der Deutschen Diabetes-Gesellschaft
Bettin Baumann
Postfach 1182
67321 Speyer
E-Mail: Bettinabaumann1970@web.de
Internet: www.ag-fuss-ddg.de
Bundesverband Klinischer Diabetes-
Einrichtungen e.V.
Bundesgeschäftsstelle
Diabeteszentrum Bad Lauterberg
Kirchberg 21
37431 Bad Lauterberg
Tel.: 0 55 24 / 81 - 2 12
Fax: 0 55 24 / 81 - 7 77
E-Mail: info@BVKD.de
Internet: www.bvkd.de
Deutsche Diabetes-Stiftung (DDS)
Staffelseestr. 6
81477 München
Tel.: 0 89 / 57 95 79 - 0
Fax: 0 89 / 57 95 79 - 19
E-Mail: info@diabetesstiftung.de
Internet: www.diabetesstiftung.de
51
Addresses
diabetesDE
Geschäftsstelle
Reinhardtstraße 31
10117 Berlin
Tel: 0 30 / 20 16 77 0
Fax: 0 30 / 20 16 77 20
E-Mail: info@diabetesDE.org
Internet: www.diabetesde.org
Stiftung „Der herzkranke Diabetiker“
in der DDS
Georgstraße 11
32545 Bad Oeynhausen
Fax: 0 57 31 / 97 21 22
E-Mail: info@der-herzkranke-diabetiker.de
Internet: www.stiftung-dhd.de
Verband der Diabetes-Beratungs- und
Schulungsberufe in Deutschland e.V. (VDBD)
Am Eisenwald 16
66386 St. Ingbert
Tel.: 0 68 94 / 5 90 83 13
Fax: 0 68 94 / 5 90 83 14
E-Mail: info@vdbd.de
Internet: www.vdbd.de
52
Bundesverband und Landesverbände des
Deutschen Diabetiker Bundes
Deutscher Diabetiker Bund e. V. (DDB)
Bundesverband
Goethestr. 27
34119 Kassel
Tel.: 0 5 61 / 70 34 77 0
Fax: 0 5 61 / 70 34 77 1
E-Mail: info@diabetikerbund.de
Internet: www.diabetikerbund.de
Landesverbände
LV Baden-Württemberg e. V.
Elke Brückel
Kriegsstr. 49
76133 Karlsruhe
Tel.: 07 21 / 3 54 31 98
Fax: 07 21 / 3 54 31 99
info@ddb-bw.de
www.ddb-bw.de
Verband Deutscher Podologen (VDP)
Obere Wässere 3-7
D-72764 Reutlingen
Tel.: +49 7121 / 33 09 42
Fax: +49 7121 / 31 00 89
E-Mail: volker.pfersich@verband-deutscher-podologen.de
LV Bayern e. V.
Bernd Franz
Diabetikerbund Bayern e. V.
Ludwigstr. 67
90402 Nürnberg
Tel.: 0911 / 22 77 15
Fax: 0911 / 23 49 876
info@diabetikerbund-bayern.de
www.diabetikerbund-bayern.de
Zentralverband der Podologen und Fuss
pfleger Deutschlands e.V. (ZFD)
Schaumburgstraße 14-16
45657 Recklinghausen
Tel.: 0 23 61 / 18 59 60
Fax: 0 23 61 / 18 59 61
E-Mail: info@zfd.de
Internet: www.zfd.de
LV Berlin
Reiner Tippel
Schillingstr. 12
10179 Berlin
Tel.: 0 30 / 2 78 67 37
Fax: 0 30 / 2 75 91 657
ddbberlin@arcor.de
www.diabetikerbund-berlin.de
Addresses
LV Brandenburg e. V.
Eberhard Nowotnik
Schopenhauerstr. 37
14467 Potsdam
Tel.: 03 31 / 9 51 05 88
Fax: 03 31 / 9 51 05 90
info@diabetikerbund-brandenburg.de
www.diabetikerbund-brandenburg.de
LV Niedersachsen e.V.
Almut Suchowerskyj
Am Nottbohm 46a
31141 Hildesheim
Tel.: 0 51 21 / 87 61 73
Fax: 0 51 21 / 87 61 81
ddb-nds-as@t-online.de
www.ddb-niedersachsen.de
LV Bremen e.V.
Hartmut Steinbeck
Am Wall 102
28195 Bremen
Tel.: 04 21 / 6 16 43 23
Fax: 04 21 / 6 16 86 07
info@ddb-hb.de
www.ddb-hb.de
LV Nordrhein-Westfalen e.V.
Martin Hadder
Johanniterstr. 45
47053 Duisburg
Tel.: 02 03 / 6 08 44 - 0
Fax: 02 03 / 6 08 44 - 77
diabetikerbund@ddb-nrw.de
www.ddb-nrw.de
LV Hamburg e.V.
Manfred Mohnke
Steinstraße 15
20095 Hamburg
Tel.: 0 40 / 20 00 43 80
Fax: 0 40 / 20 00 43 88
info@diabetikerbund-hamburg.de
www.diabetikerbund-hamburg.de
LV Rheinland-Pfalz e.V.
Alois Michel
Theodor-Fliedner-Str. 25
55218 Ingelheim
Tel: 0 61 32 / 8 59 77
Fax: 0 61 32 / 71 21 96
mlamichel@aol.com
www.diabetes-rlp.de
LV Hessen e.V.
Prof. Dr. Hermann von Lilienfeld-Toal
Friedrich-Ebert-Str. 5
34613 Schwalmstadt-Treysa
Tel.: 0 66 91 / 2 49 57
Fax: 0 66 91 / 2 49 58
info@ddbhessen.de
www.ddbhessen.de
LV Saarland e.V.
Karl Zang
Wolfskaulstr. 43
66292 Riegelsberg
Tel.: 0 68 06 / 95 35 71
Fax: 0 68 06 / 95 35 72
ddbsaarland@t-online.de
www.diabetiker-saar.de
LV Mecklenburg-Vorpommern
LV in Gründung.
RA Dietrich Monstadt
Lübecker Str. 5
19053 Schwerin
LV Sachsen e.V.
Rosmarie Wallig
Striesener Str. 39
01307 Dresden
Tel.: 03 51 / 4 52 66 52
Fax: 03 51 / 4 52 66 53
info@Diabetikerbund-Sachsen.de
www.Diabetikerbund-Sachsen.de
53
Addresses
LV Sachsen-Anhalt e.V.
Reinhold Meintzinger
Neuer Weg 22/23
06484 Quedlinburg
Tel. und Fax: 03946/528483
info@diabetikerbundsa.de
www.diabetikerbundsa.de
LV Schleswig-Holstein e.V.
Martin Lange
Auguste-Viktoria-Str. 16
24103 Kiel
Tel.: 04 31 / 18 00 09
Fax: 04 31 / 12 20 407
info@ddb-sh.de
www.ddb-sh.de
LV Thüringen e.V.
Edith Claußen
Waldenstraße 13a
99084 Erfurt
Tel./Fax: 03 61 / 7 31 48 19
ddb-thueringen@gmx.de
www.ddb-thueringen.de
Useful international Adresses
EASD
Rheindorfer Weg 3
40591 Düsseldorf
Germany
Tel.: +49/211-758 469 0
Tel.: +49/211-758 469 29
secretariat@easd.org
Executive Director: Dr. Viktor Jörgens
IDF
International Diabetes Federation
Chaussée de la Hulpe 166
B-1170 Brussels, Belgium
Tel.: +32/2-5 38 55 11
Tel.: +32/2-5 38 51 14
info@idf.org
Websites of Self-Help Groups
http://www.selbsthilfenetz.de/content/index_
ger.html
http://www.dag-selbsthilfegruppen.de/site/
http://www.koskon.de/
54

Skin - Allpresan

Transcription

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