European Journal of Cardiovascular Medicine

Type 2 diabetes (DM2) has become an epidemic and led to a large public health burden in India, which currently ranks as the second leading country for diabetes sufferers, estimated to increase to over 134 millions by 2045 [1]. Although metabolic and vascular complications of DM2 have been thoroughly investigated, dermatologic involvement—specifically, chronic pruritus—is a less commonly recognized and studied feature in the clinical setting.

It may present locally or spread across (generalized), and in a chronic form (>6 weeks) becomes a burden to the quality of the patient’s life [2]. Chronic itch in DM2 is frequently multifactorial and implicated in poor glycemic control, diabetic polyneuropathy, skin xerosis and autonomic dysfunction affecting sweat glands [3, 4]. The prevalence of itch among diabetic patients ranges from 18% to 35% reported from a cross section study globally [5], Indian data are lacking.

A very few Indian studies have addressed dermatological manifestations in DM2 though they were confined to infections or the classical dermatoses like diabetic dermopathy and acanthosis nigricans [6]. Nevertheless, the psychosocial impact of pruritus, including sleep disturbance, anxiety, depression and social embarrassment, has been underappreciated. In rural and marginalized communities, its burden may be even greater because people in these areas might be poorly informed about dermatological health, and have limited access to a specialist [7].

There is also an accumulating body of evidence that chronic itch in DM2 is not simply a dermatological symptom, but that it could be an early clinical sign of diabetic neuropathy or poor metabolic regulation [8]. In India particularly, where very few patients reach their glycaemic goal, a search for pruritus as an index of systemic derangements becomes of utmost importance [9].

The objective of the study is to evaluate the prevalence, clinical features, and probable etiopathogenetic factors for chronic itch (CI) in adult type-2 diabetes mellitus patients, in a tertiary care teaching hospital in India. Through uncovering the potential etiological and psychological factors associated with this phenomenon, the study may draw attention to the need for dermatological symptom assessment in the context of standard diabetes care.

This was a cross-sectional study carried out between February 2023 and February 2025 at Endocrinology, and Dermatology OPDs of a teaching hospital in India. Three hundred and fifty-four adult patients with type 2 DM (DM2) were selected through simple random sampling. A 95% confidence level and 5% absolute precision were used to determine sample size, based on a previous itch prevalence of 35.8% 19, 20.

All patients were older than 18 years and diagnosed with DM2 and were included after informed consent was obtained. Patients with primary dermatologic diseases, antipruritic or neuropathic agents, cognitive impairment or systemic disease were excluded.

Structured interviews and clinical evaluations were employed in data collection. Itch was assessed by Numerical Rating Scale (NRS). Katzenwadel scale was used to assess diabetic neuropathy, and ItchyQoL, HADS. Previous laboratory results including HbA1c and serum creatinine level were collected. Data were analyzed using SPSS v25. 0 using the proper statistical tests (Mann-Whitney U, χ 2, Pearson/Spearman) at p < 0.05. The study was conducted after obtaining ethical clearance from the Institutional Ethics Committee as per the declaration of Helsinki.

Table 1: Demographic and Clinical Characteristics of the Study Population (n = 354)

A total of 354 patients with type 2 diabetes mellitus were evaluated in this study. The average age of the patients was 53.4 ± 9.1 years, and 184 (52.0%) were men, while 170 (48.0%) were women. The mean duration of diabetes of the participants was 7.5 ± 1.9 years. The average BMI was 23.9 ± 1.4 kg/m², and most individuals were categorized as normal to overweight.

Table 2: Prevalence and Severity of Pruritus among Study Participants.

Pruritus was reported from 139 (prevalence 39.3%) of the 354 participants who were included in the study. The 215 (60.7%) others did not have an itch symptom. The severity of pruritus was graded by the numeric rating scale (NRS) in respondents with pruritus. Mild pruritus, NRS score 1–3: 38 (27.3%), moderate pruritus, NRS score 4–6: 67 (48.2%), severe pruritus, NRS score 7–10: 34 (24.5%). This pattern of distribution implies that almost three quarters of the affected suffered from pruritus of moderate to severe degree showing that it may contribute to poor quality of life in diabetics.

Table 3: Comparison of Metabolic Parameters between Patients with and Without Pruritus

Comparison of metabolic profiles in individuals with and without pruritus Significant differences in glycemic control were found between both pruritic and non-pruritic subjects. HbA1c was also higher in those reporting pruritus compared to those who did not (mean 8.6 ± 1.2% vs 7.9 ± 1.0%, p = 0.003), and thus suggesting poorer long-term glucose regulation in the itchy group.

Table 4: Skin Xerosis and Neuropathy Scores in Relation to Pruritus Status

There was a significant difference in skin xerosis and neuropathy scores among subjects with and without pruritus. Mean clinical xerosis score was significantly higher in pruritic patients (2.1 ± 0.6) compared to the non-pruritic subjects (1.3 ± 0.5) (p < 0.001), reflecting more severe skin dryness among those who had itch. In addition, patients with pruritus had significantly higher mean neuropathy score on the Katzenwadel scale (7.4 ± 2.2) than those without (5.1 ± 1.9), with p < 0.001. These findings suggest that xerosis is significantly correlated to the presence of pruritus in type 2 diabetes mellitus patients as well as peripheral neuropathy.

Table 5: Spearman’s Correlation

Analysis between Skin Xerosis and Neuropathy Scores

The Spearman rank correlation of Skin Xerosis (Clinical Scale) with “Neuropathy (Katzenwadel Scale)” showed moderate positive relationship which was calculated as (r = 0.65). This suggests a relationship between skin xerosis and neuropathy severity in patients with type 2 diabetes mellitus. The p value is significantly less than 0.001; consequently, the association between skin dryness and neuropathy is an unlikely chance finding. This result is consistent with other studies, which have reported that both skin dryness and neuropathy are frequent complications of diabetes and that these may be correlated because they share mechanisms, such as autonomic dysfunction and poor metabolic control. Therefore, these findings emphasize the importance of effective management strategies that consider dermatological and neuropathic aspects in diabetic individuals.

Table 6: Quality of Life and Psychological Scores among Patients with Pruritus.

Quality of life and psychosocial well-being were substantial in patients with pruritus. A moderate to high degree of impact of itch on day-to-day activities and quality of life was indicated with a mean ItchyQoL total score of 42.7 ± 8.5. Results of the HADS indicated high scores for both anxiety (M = 9.3, SD = 2.1) and depression (M = 8.1, SD = 1.9), indicating high levels of emotional distress in the affected sample. These results emphasize the psychological and social impacts of CKD-aP in patients with T2DM.

The prevalence, severity, and clinical correlates of pruritus were assessed in subjects with type 2 diabetes mellitus (DM2) in a cross-sectional study at a tertiary care hospital in India. The findings reflect an excessive burden of pruritus that 39.3% of participants experienced, which is similar to the previous international estimates of 18-42% in diabetic populations [10,11]. This is in accordance to the prevalence found by Stefaniak et al., who found 35.8% prevalence in a European DM2 cohort [12], thereby indicating that pruritus is a common yet under-diagnosed complication of diabetes in different populations including Indians.

The degree of pruritus identified in our study was significant, with at least three-quarters of those affected having moderate or severe itch. This represents a clinically significant impact, in line with the higher scores of the ItchyQoL, HADS, and 6-ISS scales. The mean ItchyQoL score (42.7 ± 8.5) in our sample was similar to those that have been reported in previous series of chronic dermatologic and systemic diseases [13], supporting the detrimental effect of pruritus on psychological and functional status.

Most importantly, we found a strong correlation between pruritus and poor glycemic control. Patients with pruritus presented with higher levels of HbA1c (8.6% against 7.9%) as well as with fasting plasma glucose, underlining hyperglycemia as a potential etiologic factor. It has been suggested that chronic hyperglycemia could drive neuropathic alterations and skin barrier impairment, which may potentiate itch [14, 15].

Skin dryness was much more pronounced in patients with pruritus, and a subjective clinical score as well as a decrease in corneometric values confirmed this. Xerosis has always been linked to diabetes-related pruritus in the previous [16] literature with its pathophysiological background being autonomic dysfunction, reduced sweat production and lipid metabolism changes causing skin inelasticity. Our study found that the average score of the clinical xerosis was higher in pruritic subjects than non-pruritic patients (2.1 ± 0.6 vs 1.3 ± 0.5) confirming it to be a useful clinical indicator.

There was also more severe neuropathy among pruritus patients with higher Katzenwadel scores. This is also consistent with other studies (Yamaoka et al. and Pereira et al. who also recognized truncal or generalized pruritus as a neuropathic sign of diabetes [17,18]. It is now being recognized that DIEP includes not only pain but also dysesthetic symptoms including itch, as mediated by small unmyelinated nerve fibers [19].

Psychologically, pruritus patients had high anxiety and depression scores on the HADS, along with a double physical and emotional load. Chronic itch was previously demonstrated to affect sleep, concentration, and self-esteem, thereby resulting in psychological suffering [20]. Furthermore, the high scores on the Six-Item Stigmatization Scale (mean 5.4 ± 1.6) also highlight the psychosocial implications, particularly in societies where visible scratching or skin alterations are socially embarrassing.

These findings highlight the need for a multidisciplinary approach to managing diabetes, incorporating dermatological and psychological screening into routine care. Simple clinical assessments such as xerosis grading and itch scales, combined with optimized glycemic control and neuropathy evaluation, may improve symptom recognition and patient outcomes.

This study shows that pruritus is a relatively frequent and clinically relevant complication in patients with diabetes mellitus type 2 in 39.3% of the patients. Pruritus was significantly correlated with suboptimal glycemic control, increased neuropathy scores, and more severe skin xerosis. Furthermore, affected patients showed a significant psychological burden with high levels of anxiety, depression, and perceived stigmatization. These results highlight the relevance of periodic assessment of pruritus and its attributable causes as part of diabetic care, favoring a multidisciplinary focus toward addressing metabolic as well as dermatological well-being in order to better serve the patient.

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