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Necrobiosis lipoidica is a skin disorders with an interesting predisposition for areas of trauma such as the anterior shins. In this report a patient with diabetes mellitus and generalized necrobiosis lipoidica diabeticorum with localization in surgical scars is described. A brief review of other skin disorders occurring in scars is also included.
The microradiogram of granuloma anulare was compared with that of necrobiosis lipoidica. In the areas of cellular infiltration, the amount of connective tissue missing depended on the degree of infiltration. Apparently the collagenous bundles were destroyed, not pushed aside. In the necrobiotic type of necrobiosis lipoidica, the damage to collagenous tissue was more severe than one would have expected from the stained sections. The collagenous bundles were generally swollen, and there was a complete lack of normal high-density bundles in the damaged areas, in contrast to granuloma anulare and to the granulomatous type of necrobiosis lipoidica, however, the damage to the collagenous tissue seemed less severe in the microradiograms than in the stained sections. Differences between granuloma anulare and necrobiosis lipoidica were to be found in the microradiogram (see tables), but in general a differential diagnosis is only possible in severe cases, in spite of the different clinical picture.
Necrobiosis lipoidica belongs to the inflammatory granulomatous skin disorders groups with palisade reaction. The association to diabetes mellitus is classical involving 80% of diabetics in its tibial localization. A retrospective study of all cases of necrobiosis lipoidica conducted in our dermatology department over a-15-year period, found 4 diabetic patients, 3 of whom were women known as diabetic patient with extremities involvement, and 1 man not known as diabetic patient at the time of the diagnosis. Necrobiosis lipoidica appears to be a rare disorder in diabetic people and this association seems to be over estimated.
Necrobiosis lipoidica diabeticorum is briefly described. Its high coincidence with hyperlipoproteinaemia in casuistic reports from the literature as well as in about half of the 22 cases observed in our clinic can be taken in favour of possible relations between these conditions. Disturbances of fat metabolism may even be considered important for pathogenesis of necrobiosis in general, the more as at least no optimally regulated fat and carbohydrate metabolism can be achieved by best therapeutic control of carbohydrate parameters in juvenile diabetics. Microangiopathia diabetica seems to exist from the very beginning of diabetes mellitus and may ne a basic etiologic prerequisite for the development of necrobiosis. Topical conditions of certain body regions are said to take part in final precipitation of necrobiotic spots.
Necrobiosis lipoidica diabeticorum (NLD) is an idiopathic granulomatous skin disorder. We review previously described therapies from the recent literature and report the first case of successful treatment of NLD with oral chloroquine.
Necrobiosis lipoidica is often resistant to therapeutic intervention. Lesions are atrophic and frequently ulcerate. A case is presented in which atrophy was diminished by the application of topical tretinoin. The practical and theoretical use of topical tretinoin in this disorder is reviewed.
Necrobiosis lipoidica (NL) has distinctive clinical and histological appearances. The legs are the commonest site of involvement, and 85% of cases involve the legs exclusively. We describe a patient in whom NL did not involve the legs, but was found to occur on unusual areas: the back and nipple. This is possibly the first report of NL affecting the nipple.
Necrobiosis lipoidica diabeticorum (NLD) is a condition that can be physically and psychologically distressing. Angiopathy leading to thrombosis and occlusion of the cutaneous vessels has been implicated in its etiology. Pentoxiphylline is a hemorrheological agent that improves blood flow and decreases red cell and platelet aggregation. Based on these data, aim of our study was to report clinical course of a 20-yr-old diabetic woman with NLD during therapy with Pentoxiphylline 400 mg 3 times daily. After 1 month of therapy, the lesions stopped enlarging. After 3 months, the lesions showed initial signs of healing. At 6-month follow-up, there was near resolution of the lesions. The patient continued therapy and remained in remission at 2-yr follow-up. This improvement relieved psychological stress on the patient. No side effects of treatment were reported. In conclusion, patients with NLD may benefit from treatment with pentoxiphylline. We recommend therapy with 400 mg 3 times daily. The drug should be continued for at least 6 months.
Alpha 2-macroglobulin, caeruloplasmin and haptoglobin were measured in the sera of patients with necrobiosis lipoidica, granuloma annulare and diabetes. Alpha 2 Macroglobulin and caeruloplasmin were significantly raised in diabetes, and caeruloplasmin was raised in necrobiosis lipoidica without diabetes. The ratio of alpha 2-globulin to serum albumin was significantly high for all three proteins in diabetes, and for haptoglobin and caeruloplasmin in necrobiosis lipoidica. None of these proteins was abnormally raised in non-diabetic patients with granuloma annulare. There is good evidence that the plasma protein changes in diabetes contribute to the development of microangiopathy by their influence on blood viscosity. The altered plasma protein profile in necrobiosis lipoidica may therefore be of relevance to the development of the vascular lesions in this disorder.
A case of aggressive ulceration of necrobiosis lipoidica was successfully treated with oral prednisolone. A retrospective study of 23 cases of necrobiosis lipoidica revealed a 13% incidence of ulceration. The pathogenesis, clinical features and treatment of ulceration in necrobiosis lipoidica are discussed.
We report the case of a female patient with necrobiosis lipoidica of the lower legs and coexistent systemic and cutaneous sarcoidosis. We review the six previously reported patients with coexisting necrobiosis lipoidica and sarcoidosis. The associations between the granulomatous disorders of the skin, especially necrobiosis lipoidica, sarcoidosis and granuloma annulare, are discussed. The common pathogenetic features of these disorders are reviewed.
Transcutaneous measurement of oxygen pressure (PcO2) and carbon dioxide pressure (PcCO2) was performed in nine patients with histologically confirmed necrobiosis lipoidica. None of the patients had diabetes mellitus. All measurements were taken at the lower leg. In each case, the atrophic center, the inflamed border, and the surrounding clinically normal skin of necrobiosis lipoidica were examined at 44 degrees C sensor temperature (maximal vasodilatation). Statistically significant hypoxia was found in the area of necrobiosis lipoidica, which was even more pronounced in the inflamed border. Inhalation of 100% oxygen provoked a marked increase in the PcO2 in the lesion, but the values were still significantly lower than in the normal skin. At the edge of the lesions the PcCO2 was significantly elevated. These findings support a vascular origin of necrobiosis lipoidica, involving reduced vascular perfusion combined with diffusion block.
We report a case of necrobiosis lipoidica located on the glans penis of a patient without diabetes mellitus. Both clinical and histologic features favor the diagnosis of necrobiosis lipoidica, even though the location is unusual. Treatment with pentoxifylline was effective. The differential diagnosis is discussed.
Granuloma annulare and necrobiosis lipoidica diabeticorum have rarely been reported in the same patient. We describe the unusual case of a woman with diabetes and a history of generalized granuloma annulare who noted leg ulcers that clinically represented ulcerated necrobiosis lipoidica diabeticorum and had histologic features of necrobiosis lipoidica diabeticorum and granuloma annulare. Her condition responded to treatment with antiplatelet agents.
Cutaneous sensation in plaques of necrobiosis lipoidica was assessed in five non-diabetic and seven diabetic patients. Eleven of the twelve showed partial or complete anaesthesia of the affected skin. These findings are important in the differential diagnosis of tuberculoid leprosy. Further studies of nerve function in cutaneous granulomas need to be carried out.
Necrobiosis lipoidica is a chronic degenerative disease of dermal connective tissue, of unknown etiology, which occurs mostly in diabetic patients. It may occasionally be complicated by squamous cell carcinoma. Since this combination is rare, a high index of suspicion is necessary to establish the diagnosis. We present a case and a review of the literature.
BACKGROUND: Squamous cell carcinoma in an area of chronic ulceration is a well-documented phenomenon. However, its occurrence arising de novo in an area of necrobiosis lipoidica is rare. METHOD: We report a case in a 53-year-old female who presented with a 2 month history of an erythematous nodule occurring in a plaque of necrobiosis lipoidica on the medical aspect of the right lower leg. She had a background of poorly controlled Type 1 diabetes. RESULTS: Histopathological findings revealed a well-differentiated squamous cell carcinoma overlying an area of necrobiosis lipoidica. Treatment was by excision and split-thickness skin graft. CONCLUSION: Clinicians should be aware of malignant transformation within a plaque of necrobiosis lipoidica. Early detection will allow conservative treatment.
Twelve female patients with necrobiosis lipoidica diabeticorum (six with diabetes and six without) had a 5-mm punch biopsy of the skin lesion performed. The tissue was processed for dermatopathologic examination in 12 cases and for direct immunofluorescence in 11. Vasculopathy with inflammation and thickening of vessel walls, at times leading to occlusion, was found in lesional skin in all 12 cases. Vessels contained deposits of immunoreactants in the involved skin in 11 cases. This included IgM in six, C3 in nine, fibrin in ten, IgG in one, and IgA in two. Vessels contained deposits of immunoreactants in uninvolved skin in seven patients (C3 in four, IgM in three, fibrin in three, C4 in one, and IgA in one), three of whom had type I diabetes.