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E-UPDATE--  Subject:  Updates from the Diabetes Topic Resource Center

Necrobiosis Lipoidica in a Man with Diabetes

By Ted Rosen, MD | September 25, 2012

Dr Rosen is Professor of Dermatology at Baylor College of Medicine and Chief of the Dermatology Service at the Veterans Affairs Medical Center, both in Houston, Texas.


 

 NLD, Derm DnLd Pic

 






A 34-year-old morbidly obese man was concerned about multiple lesions on both feet that were appearing rather rapidly. A review of systems disclosed polyphagia, polydipsia, and polyuria.

Key point: These lesions are composed of yellowish, firm plaques with large telangiectasia coursing over the top. There is no associated scaling. This is the typical morphology for necrobiosis lipoidica. This disorder favors the feet and forelegs.

Treatment: Potent topical or intralesional corticosteroids may make these lesions disappear. Refractory plaques may respond to oral administration of pentoxifylline(Drug information on pentoxifylline).

Note: About 70% to 80% of those with Necrobiosis Lipoidica have diabetes mellitus; however, this disorder develops in only 0.3% of all persons with diabetes. This patient’s fasting blood sugar level was 250 mg/dL and his hemoglobin A1c level was 8.8%.

FROM=MedPage, Wiki, P&P of Pod, & My Own Experience:

NLD:  A Definitive Comprehensive Review…

History and Physical Examination

History

Patients usually present with shiny, asymptomatic patches that slowly enlarge over months to years. The patches are initially red-brown and progress to yellow, depressed, atrophic plaques. Ulcerations can occur, typically after trauma and occasionally with associated pain. The patient's main complaint is the unsightly cosmetic appearance of the lesions.

Physical examination

Skin lesions of classic necrobiosis lipoidica begin as 1- to 3-mm, well-circumscribed papules that expand to form plaques with active, more-indurated borders and waxy, strophic centers. Initially, these plaques are reddish brown but progressively become more yellow, shiny, and atrophic in appearance. (See the images below.)

Typical presentation of necrobiosis lipoidica on the lower pretibial legs. Red-brown plaque with yellow atrophic center on lower leg.

Most cases of necrobiosis lipoidica occur on the pretibial area, but cases have been reported on the face, scalp, trunk, and upper extremities, where the diagnosis is more likely to be missed. Multiple telangiectatic vessels can be seen on the surface of the thinning epidermis.

Ulceration at the site of trauma and subsequent infection are occasional complications of necrobiosis lipoidica. The Koebner phenomenon has been well established in patients with necrobiosis lipoidica, especially in patients with vasculitis at the site of trauma.[4]

Miller reported a case of a woman with known type 1 diabetes mellitus who developed biopsy-proven necrobiosis lipoidica in a cholecystectomy scar and also on her abdomen at insulin injection sites.

In most patients, the lesions of necrobiosis lipoidica are multiple and bilateral. The lesions may become painless because of cutaneous nerve damage (75% of cases), or they may be extremely painful (25% of cases).

 

Necrobiosis lipoidica is a disorder of collagen degeneration with a granulomatous response, thickening of blood vessel walls, and fat deposition. The main complication of the disease is ulceration, usually occurring after trauma. Infections can occur but are uncommon. There have been rare reported cases of squamous cell carcinomas developing in chronic lesions of necrobiosis lipoidica. (See Etiology, Prognosis, Presentation, and Workup.)[1, 2]

The condition was first described in 1929, by Oppehhein, who called it dermatitis atrophicans lipoidica diabetica; in 1932, however, the disease was renamed necrobiosis lipoidica diabeticorum (NLD), by Urbach.

In 1935, Goldsmith reported the first case in a nondiabetic patient. Other cases of necrobiosis lipoidica diabeticorum in nondiabetic patients were described by Meischer and Leder, in 1948. Rollins and Winkelmann, in 1960, also described this condition in nondiabetic patients, and a renaming of the disorder was suggested to exclude diabetes from the title.[3] Today, the term necrobiosis lipoidica is used to encompass all patients with the same clinical lesions, regardless of whether or not diabetes is present. (See Presentation and Workup.)