OBSERVATIONS Implantable Pump Therapy Restores Metabolic Control and Quality of Life in Type 1 Diabetic Patients With Buschke’s Nonsystemic Scleroderma B uschke’s nonsystemic scleroderma is an uncommon dermatosis charac- terized by thickened and indurate skin of unknown origin, mostly affecting upper parts of the body but also the ab- dominal area. While diabetes is rarely as- sociated, subcutaneous insulin treatment may be hardly feasible and effective be- cause of incomplete absorption of insulin (1). After approval of our institutional ethical committees, four type 1 diabetic patients (one male and three female sub- jects) affected by this condition received Medtronic MiniMed implantable pumps (Northridge, CA) for intraperitoneal insu- lin delivery (2) between 1994 and 2004. The patients, aged 45.2  2.9 years, had a mean duration of diabetes of 33.5  1.3 years, including multiple microvascular complications. Biopsies of the affected skin, performed in three patients, con- firmed expanded dermis with enlarged collagen bundles and, in one case, visible mucin. None had evidence of systemic sclerosis by biopsy and other investiga- tions at baseline or during follow-up. Skin status was clinically assessed on a yearly basis, diabetes complications surveyed as required, and HbA 1c (A1C) measured us- ing a high-performance liquid chroma- tography method (normal values 5.6%) on a quarterly basis. From implantation time, improve- ment of glucose control was sustained as shown by mean yearly A1C moving from 9.3  0.7% (baseline) to 7.9  1.3% (2005). Microvascular complications re- mained stable or decreased. All patients experienced a dramatic decrease of skin induration as early as a few months after implantation. We found clinical improve- ment of the skin aspect in terms of red- ness, swelling, and induration, even if we did not have tools at our disposal to mea- sure skin elasticity. Several published case reports de- scribe either poorly effective therapeutic options for Buschke’s scleroderma (3,4) or the effective, albeit rather extreme, ra- diation therapy (5). Poor glycemic control may play a role in worsening of the skin condition, resulting in a vicious cycle of worsening control and worsening disease driven by poor absorption of insulin (6). Although not documented by pathologi- cal or biochemical skin analyses, our find- ings support previous hypotheses that glucose excess causes impairment through increased glycation alterations of tissue collagen, which are involved in Buschke’s scleroderma, and that this pro- cess can be reversed with improved glu- cose control. We suggest implantable pump therapy as an option in patients with type 1 diabetes affected by this un- common skin condition when optimized subcutaneous insulin treatment fails to achieve acceptable blood glucose control. SABINE BAILLOT-RUDONI, MD 1 DOMINIQUE APOSTOL, MD 2 GENEVIE ` VE VAILLANT, MD 1 JEAN-MARCEL BRUN, MD 1 ERIC RENARD, MD, PHD 2 ON BEHALF OF THE EVADIAC STUDY GROUP From the 1 Department of Endocrinology and Meta- bolic Diseases, Bocage Hospital, Dijon, France; and the 2 Endocrinology Department, Lapeyronie Hospi- tal, Montpellier, France. Address correspondence to Sabine Baillot- Rudoni, MD, Department of Endocrinology and Metabolic Diseases, Bocage Hospital, 21079 Dijon, France. E-mail: sabine.rudoni@dijon.fr. DOI: 10.2337/dc06-0582 © 2006 by the American Diabetes Association. ●●●●●●●●●●●●●●●●●●●●●●● References 1. Jabbour SA: Cutaneous manifestations of endocrine disorders: a guide for derma- tologists. Am J Clin Dermatol 4:315–331, 2003 2. Broussolle C, Jeandidier N, Hanaire- Broutin H, the EVADIAC Study Group: French multicenter experience of im- plantable insulin pumps. Lancet 343:514 – 515, 1994 3. Seyger MM, Van Den Hoogen FH, De Mare S, Van Haelst U, De Jong EM: A pa- tient with a severe scleroedema diabetico- rum, partially responding to low-dose methotrexate. Dermatology 198:177–179, 1999 4. Krasagakis K, Hettmannsperger U, Traut- mann C, Tebbe B, Garbe C: Persistent scleredema of Buschke in a diabetic: im- provement with high-dose penicillin (Let- ter). Br J Dermatol 134 :597–598, 1996 5. Bowen AR, Smith L, Zone JJ: Scleredema adultorum of Buschke treated with radia- tion. Arch Dermatol 139:780 –784, 2003 6. Buckingham BA, Uitto J, Sandborg C, Keens T, Roe T, Costin G, Kaufman F, Bernstein B, Landing B, Castellano A: Scleroderma-like changes in insulin-de- pendent diabetes mellitus: clinical and biochemical studies. Diabetes Care 7:163– 169, 1984 Possible Problem With Optipen Pro-1 Should diabetic patients continue to use this product? I nsulin glargine is a modified basal in- sulin analog that has been recently in- troduced and is now available worldwide. Insulin glargine is available in 3-ml cartridges that can be used with the OptiPen Pro-1 (Sanofi-Aventis). The Medicines and Healthcare Products Reg- ulatory Agency (MHRA; executive agency of the Department of Health in the U.K., which enhances and safeguards the health of the public by ensuring the effectiveness of medicines and medical devices) has re- ceived a significant number of reports concerning difficulties in the operation and use of the OptiPen Pro-1 insulin pen injection system. A fault was found with some batches of the OptiPen Pro-1 sys- tem, whereby the dosage button failed to engage at the end of an injection (1). A total of 32 type 1 diabetic patients (age 17.0  4.4 years [mean  SD]) on multiple daily injection regimens, who had been treated with insulin for at least for 6 months and were insulin glargine naive, were transferred from NPH insulin to insulin glargine between May 2004 and March 2005. Two patients without any evidence of infection or of skipped insulin doses had ketosis on the 3rd and 4th month of insulin glargine treatment, re- spectively. When the patients were ques- tioned about the reasons for ketosis, they stated leakage of insulin from the sides of the pen during injection. An inquiry form regarding OptiPen Pro-1 was given to all subjects on the 6th month of therapy. Leakage from the sides of the pen was noted by 58.8% of sub- jects, and a problem with the dosage but- ton not locking when it was fully depressed following injection of the de- sired dose of insulin was reported by 38.2%. The patients were asked to rate L E T T E R S 1710 DIABETES CARE, VOLUME 29, NUMBER 7, JULY 2006