(P13) Management of Type 2 Diabetes with Familial Palmoplantar Keratoderma

Introduction: Palmoplantar Keratoderma is an uncommon disorder characterized by hyperkeratosis in the epidermis of the palms and soles, leading to the development of abnormally thickened skin. This disorder can be acquired or inherited, interfering with the routine fingerstick glucose monitoring required for managing diabetes mellitus.

Case Description: 76-year-old male with a history of palmoplantar keratoderma, type 2 diabetes mellitus, atrial fibrillation (on Warfarin), and Cerebrovascular accident (CVA) with hemiparesis recently admitted to a skilled nursing facility (SNF) due to functional decline and debility. Due to hemiparesis and palmoplantar keratoderma, he had relied on Continuous Glucose Monitoring (CGM) for 6 months before his SNF admission. In the absence of a nursing home policy at the facility for the utilization of CGM for patients with diabetes, fingerstick glucose monitoring was commenced in its place. At the time of his initial recertification visit, it was noted on an exam that the patient had multiple areas of bleeding under the hyperkeratinized fingertips. This resulted after several layers of keratin needed to be removed to access the skin for lancet use to obtain routine fingerstick glucose levels. After reaching out to organizations involved in long-term care patients and with a discussion with the SNF leadership, a new nursing policy was made to allow the use of his CGM to manage his diabetes.

Discussion: Palmoplantar keratoderma poses a unique challenge in monitoring diabetes mellitus. The presence of hyperkeratosis of the palms and fingertips is a physical barrier to utilizing traditional glucose monitoring methods through fingersticks and other point-of-care tests such as monitoring for INR. CGM is a practical alternative to fingerstick monitoring glucose levels in diabetic patients. For patients residing at home or within a hospital setting, Medicare covers 80% of the cost of CGM supplies (including the G4 sensor, transmitter, and receiver) with the allowance of smartphone phone application monitoring. However, in the case of SNF residents, all routine glucose monitoring, including CGM, is not covered through Medicare Part B under the Social Security Act. Implementing a CGM policy in nursing homes for diabetes management can provide safe, compassionate, and cost-effective glucose monitoring in selected patients.