Diabetic Autonomic Neuropathy

Aaron I. Vinik, MD, PhD.; Roy Freeman, MB, ChB.; Tomris Erbas, MD


Semin Neurol. 2003;23(4) 

In This Article

Impaired Microvascular Skin Blood Flow

Microvascular skin flow is under the control of the ANS and is regulated by both the central and peripheral components. In diabetes, the rhythmic contraction of arterioles and small arteries is disordered. Microvascular insufficiency may be a cause of diabetic autonomic neuropathy.[33] Defective blood flow in the small capillary circulation is found with decreased responsiveness to mental arithmetic, cold pressor, handgrip, and heating.[15] The defect is associated with a reduction in the amplitude of vasomotion and resembles premature aging.[34] There are differences in the glabrous and hairy skin circulations. In hairy skin, a functional defect is found before the development of neuropathy.[35,36] The clinical counterpart is dry skin, loss of sweating, and the development of fissures and cracks that are portals of entry for microorganisms, leading to infectious ulcers and ultimately gangrene. Autonomic neuropathy may also lead to increased osteoclastic activity resulting in reduced bone density. The significant relationship between reduced bone mineral density and severity of diabetic neuropathy in the lower extremities of individuals with Charcot neuroarthropathy may reflect the severity of autonomic neuropathy.


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