Differentiating obesity with and without prediabetes through skin findings: results from PREVIEW sub-study

Category	Detail
Condition	Prediabetes in adults with overweight or obesity
Key Mechanisms	Insulin resistance and beta-cell dysfunction leading to dysglycemia; associated cutaneous manifestations including horseshoe-like plantar hyperkeratosis
Target Population	Adults aged 23–70 years with overweight or obesity (BMI ≥25 kg/m²), Fitzpatrick skin phototype II and III
Care Setting	Primary care and dermatology outpatient settings for metabolic risk screening

Horseshoe-like plantar hyperkeratosis (HSLPH) is significantly more frequent in adults with overweight or obesity who have prediabetes compared to those without.
HSLPH shows high specificity (90%) but low sensitivity (25%) for prediabetes, making it a specific but insensitive clinical sign.
Other common obesity-related skin findings such as skin tags, onychomycosis, chronic venous insufficiency signs, seborrheic dermatitis, and tinea pedis do not discriminate prediabetes status.

Consider the presence of horseshoe-like plantar hyperkeratosis as a visible clinical red flag prompting metabolic evaluation for prediabetes in adults with overweight or obesity.
Use oral glucose tolerance test (OGTT) and ADA criteria (fasting plasma glucose, 2-hour plasma glucose, HbA1c) for definitive diagnosis of prediabetes.

Implement lifestyle interventions targeting weight reduction and metabolic risk in patients identified with prediabetes.
Use skin examination as an adjunct to identify individuals at higher risk but do not rely solely on cutaneous signs for diagnosis.

Monitor glycemic status regularly in patients with overweight or obesity, especially if HSLPH is present.
Assess skin changes periodically as part of comprehensive metabolic risk evaluation.

Absence of HSLPH does not exclude prediabetes; low sensitivity limits its use as a screening tool alone.
Common obesity-related skin conditions are not reliable indicators of prediabetes.

Adults with overweight or obesity undergoing metabolic risk assessment

Presence of HSLPH may guide clinicians to prioritize metabolic evaluation and early intervention, but absence should not delay testing or management.

Perform standardized skin examinations focusing on plantar hyperkeratosis in adults with overweight or obesity during metabolic risk screening.
Use visual numeric scales to assess xerosis, pruritus, and yellowish skin tone, recognizing these are not discriminatory for prediabetes.
Integrate dermatological findings with laboratory testing for comprehensive risk stratification.
Educate patients about the significance of skin changes as potential markers of metabolic health.

Clinical Scorecard: Identifying Skin Characteristics Distinguishing Obesity with Prediabetes from Without: Insights from the PREVIEW Sub-Study