Ulcerated necrobiosis lipoidica as a rare cause for chronic leg ulcers: case report series of ten patients

Shedding Light on Photodynamic Therapy in the Treatment of Necrobiosis Lipoidica: A Multicenter Real-Life Experience

Necrobiosis Lipoidica (NL) is a dermatological condition characterized by the development of granulomatous inflammation leading to the degeneration of collagen and subsequent formation of yellowish-brown telangiectatic plaques usually localized on the pretibial skin of middle-aged females. Due to its rarity and unclear etiopathogenesis, therapeutic options for NL are not well-standardized. Among them, photodynamic therapy (PDT) is an emerging tool, although its efficacy has primarily been evaluated in single case reports or small case series. This study reports the real-life experience of a cohort of NL patients treated with PDT at the Section of Dermatology of the University Hospital of Messina and Reggio-Emilia. From 2013 to 2023, 17 patients were enrolled -5 males (29%) and 12 females (71%) aged between 16 and 56 years (mean age: 42 ± 13 years), with a median duration of NL of 8 years. The overall complete clearance (>75% lesion reduction) was 29%, while the partial clearance (25-75% lesion reduction) was 59%, with 12% being non-responders. This study adds to the little amount of evidence present in the literature regarding the effectiveness of PDT in the treatment of NL. Variability in treatment responses among patients underscores the need for personalized protocols, optimizing photosensitizers, light sources, and dosimetry. The standardization of treatment protocols and consensus guidelines are essential to ensure reproducibility and comparability across studies.

The Intersection of Dermatological Dilemmas and Endocrinological Complexities: Understanding Necrobiosis Lipoidica-A Comprehensive Review

BACKGROUND

Necrobiosis lipoidica (NL) is a rare granulomatous skin disorder with a predilection for females, often associated with diabetes mellitus (DM). This paper aims to comprehensively review the literature on NL, focusing on its association with DM, thyroid disorders, and the metabolic syndrome.

METHODS

A systematic search was conducted in English-language literature from inception to October 2023, utilizing PubMed. We identified 530 studies and selected 19 based on clinical significance, statistical support, and relevance to the paper's goals.

RESULTS

The coexistence of NL and DM is prevalent, with rates ranging from 11% to 65.71%. NL may precede DM diagnosis and a correlation between NL and increased daily insulin requirements has been observed in such patients. NL is suggested as a potential prognostic marker for DM complications; however, recent studies question this association, highlighting the need for further research. Studies in the context of NL and Thyroid Disease indicate a correlation, especially with autoimmune thyroiditis. Regarding NL and Metabolic Syndrome, the prevalence of metabolic syndrome among NL patients is notably higher than in the general population. Additionally, DM patients with ulcerated NL commonly exhibit hypertension or obesity, raising questions about the potential influence of hypertension and obesity on NL ulcerations.

CONCLUSION

Additional research is required to untangle the complex connections between NL and various comorbidities.

[Compression therapy for inflammatory dermatoses of the legs]

In addition to venous and lymphatic diseases, there is increasing scientific evidence that inflammatory dermatoses of the legs are also indications for compression therapy. Specifically, diseases such as pyoderma gangrenosum, livedoid vasculopathy, cutaneous vasculitides, necrobiosis lipoidica, psoriasis, or erysipelas are conditions for which adjunctive compression therapy may be used when manifestations occur on the lower extremities. When inflammatory dermatoses are accompanied by edema, compression therapy is not an off-label use. Especially because of the often problematic pain symptoms, compression therapy can be performed with low resting pressures around 20 mmHg, especially in inflammatory dermatoses.In this review article, the current scientific aspects of compression therapy in inflammatory dermatoses of the legs and the corresponding limitations are presented in a differentiated manner.

Treatment options for necrobiosis lipoidica: a systematic review

BACKGROUND

Necrobiosis lipoidica (NL) is a rare, idiopathic, and recalcitrant disease of collagen degeneration for which treatment options have been poorly studied. Due to its recurring nature, risk for ulceration, and high morbidity, there is a need to understand existing treatment modalities to better inform clinical care.

OBJECTIVE

This review aims to describe the therapeutic modalities reported in the literature for the treatment of NL.

METHODS

A literature search of treatments was performed by searching for publications between January 2016 and May 2022 on PubMed and Scopus. Given the limited high-quality evidence, case reports and series were included. Only publications presenting information on both attempted treatments and outcomes were included.

RESULTS

A total of 60 novel articles were identified (54 case reports, two case series, and four retrospective cohort studies). These studies cumulatively reported on 274 patients and covered treatments including phototherapy, topical corticosteroids, topical calcineurin inhibitors, biologics, immunosuppressants, JAK inhibitors, combination therapies, and several others. The greatest amount of evidence was found for photodynamic therapy (improvement in 72 of 80 patients), UVA-based phototherapy (12 of 33), topical corticosteroids (21 of 46), compression therapy (15 of 20), and topical calcineurin inhibitors (11 of 17). Several newer treatments were also described, including ustekinumab and JAK inhibitors.

CONCLUSIONS

This systematic review provides a comprehensive summary of recently published treatments for NL. As the existing data comes predominantly from case reports and series, statistical conclusions are not assessed. A greater number of randomized controlled trials with standardized endpoints are necessary to compare treatment efficacy.

Literaturrecherche zur Therapie der Necrobiosis lipoidica in der Kindheit

Die Necrobiosis lipoidica (NL) ist eine seltene granulomatöse Erkrankung mit scharf begrenzten, teleangiektatischen, braun‐roten Plaques mit atroph‐gelblichen Zentren, die zu Ulzerationen neigen und hauptsächlich an den Schienbeinen auftreten. Bei Kindern ist NL sehr selten, jedoch sind die Therapieresistenz, das problematische kosmetische Erscheinungsbild, die schmerzhaften Ulzerationen und die mögliche Entwicklung von Plattenepithelkarzinomen besonders herausfordernd für diese Altersgruppe. Unsere Literaturrecherche inkludiert 29 Berichte über NL bei Patienten unter 18 Jahren, die seit 1990 auf PubMed, EMBASE und Medline publiziert wurden. Das mittlere Alter war 14,3 Jahre mit weiblicher Prädominanz von 2 : 1 und hoher Prävalenz von Diabetes mellitus (80%). Aus den Daten geht hervor, dass hochpotente topische Steroide bis zu zweimal täglich Behandlung erster Wahl sind. Therapierefraktäre Fälle können auf Tacrolimus umgestellt werden. Ulzerationen profitieren von phasenadaptierter Wundversorgung und antientzündlichen medizinischen Verbänden wie mit medizinischem Honig. Das Hinzufügen einer hyperbaren Sauerstoffbehandlung zur lokalen oder systemischen Therapie kann bei schwer behandelbaren ulzerierten Läsionen in Betracht gezogen werden. Therapieresistente Fälle können umgestellt werden auf topische Photochemotherapie oder systemische Behandlung mit TNF‐alpha‐Inhibitoren, systemischen Steroiden (bevorzugt bei Patienten ohne Diabetes), Pentoxifyllin oder Hydroxychloroquin. Necrobiosis lipoidica in der Kindheit ist mit über 40% fehlgeschlagenen Therapieversuchen schwer zu behandeln, weshalb weitere Forschung über Patientenregister empfohlen wird.

Necrobiosis lipoidica in childhood: a review of literature with emphasis on therapy

Necrobiosis lipoidica (NL) is a rare chronic granulomatous disease that manifests as sharply demarcated, telangiectatic, brownish-red plaques with atrophic yellowish centers prone to ulceration and occurs predominantly on the shins. In children, NL is extremely rare, but resistance to therapy, troublesome cosmetic appearance, painful ulcerations, and possible development of squamous cell carcinoma in long-persisting lesions are challenges during treatment. Our review includes 29 reports of NL in patients aged <18 years published from 1990 on PubMed, EMBASE, and Medline. The mean age of patients was 14.3 years, with a female predominance of 2 : 1 and a high prevalence of diabetes mellitus (80%). Data showed that potent topical steroids up to twice daily is the first-line treatment. For refractory cases, therapy can be switched to tacrolimus. Ulcerations benefit from phase-adapted wound care and anti-inflammatory medical dressings such as medical honey. Adding hyperbaric oxygenation to local or systemic therapy in difficult-to-treat ulcerated lesions can be considered. Refractory cases may be switched to topical photochemotherapy or systemic treatment with TNF-α inhibitors, systemic steroids (preferably in non-diabetic patients), pentoxifylline, or hydroxychloroquine. Necrobiosis lipoidica in childhood is difficult to treat, with a treatment failure rate of 40%. Therefore, further research through patient registries is recommended.

Characteristics of ulcerated and non‐ulcerated necrobiosis lipoidica

BACKGROUND

Necrobiosis lipoidica (NL) is complicated by ulceration in up to 35% of cases.

METHODS

Retrospective study of patients with NL seen at our institution between January 1, 1992, and May 25, 2021, was conducted. Ulcerated NL (UNL, n = 83) and non-ulcerated NL (NUNL, n = 233) groups were compared.

RESULTS

Twenty-six percent (83/316) of patients with NL experienced ulceration. UNL was significantly more likely to be painful (52% vs. 36%, P = 0.01), was more likely to have a lesion-associated cutaneous malignancy (7% vs. 0%, P < 0.001), and had a larger median size (7 vs. 5 cm, P = 0.004) compared to NUNL. Vascular studies were performed on a subset of patients and revealed transcutaneous oxygen pressure (TcPO2) < 40 mm Hg in 53% and venous insufficiency in 62% with no significant differences between UNL and NUNL groups. In patients with unilateral ulceration, mean TcPO2 values (39.7 vs. 46.6 mm Hg), regional perfusion index <0.6 (29% vs. 14%), and TcPO2 < 40 mm Hg (43% vs. 14%) were worse in the ulcerated leg compared to the non-ulcerated leg, but these differences were not statistically significant.

CONCLUSIONS

UNL was more likely to be painful, develop lesion-associated malignancy, and be larger in size compared to NUNL. There were no statistically significant differences in venous insufficiency, arterial Doppler/ankle brachial index, or TcPO2 values between UNL and NUNL patients, however, a significant portion of the cohort demonstrated abnormal vascular studies, particularly on TcPO2 and venous insufficiency testing.

[Wound treatment in diabetes patients and diabetic foot ulcers]

Diabetes mellitus (DM) is a paramount and rising medical challenge in both industrial and emerging nations. For Germany, 6.9 million out of 64.9 million insured persons in 2010 were reported to suffer from DM and approximately 5.8 million suffered from type 2 DM. The prevalence of diabetic foot ulcer (DFU) or diabetic foot syndrome (DFS) is 2-10% and the incidence is 2-6%. In addition, patients with DM present associated skin disorders with chronic wound healing, e.g., pyoderma gangrenosum or lecrobiosis lipoidica. Knowledge of the pathogenesis and skills for treatment of chronic wounds in diabetic patients are important for dermatologists. Patients with diabetes and wound healing disorders and accompanied unspecific skin disorders like eczema, cellulitis or contact dermatitis are often primarily or secondarily treated by dermatologists. In this article, practical hints for the treatment of DFS and other chronic wound in patients with DM are presented.

Diabetic Foot Ulcers: Appraising Standard of Care and Reviewing New Trends in Management

Diabetic foot ulcers (DFU) are one of the most common diabetes complications and are associated with significant morbidity and mortality. Current DFU standard of care (SOC) involves four principles: (1) pressure relief, (2) debridement, (3) infection management, and (4) revascularization when indicated. Despite the current SOC, many DFU persist, warranting a new approach for the management of these complex wounds. This review aims to summarize the current SOC as well as the latest trends in adjunctive therapies that may become the new SOC in DFU management. These include negative pressure wound therapy and hyperbaric oxygen therapy, bioengineered skin substitutes, growth factors, shockwave therapy, and several others. These novel therapies have shown significant DFU clinical improvement among subsets of DFU patients. However, much of the literature comes from smaller trials with inconsistent patient selection and outcomes measured, making it difficult to assess the true clinical benefit of these treatments. While novel therapies are promising for the interdisciplinary approach to DFU management, many still lack sufficient evidence, and their efficacy remains to be determined.

Unmet challenges in treating hypertension in patients with borderline personality disorder: A systematic review

BACKGROUND

Caregivers encounter serious and substantial challenges in managing hypertension in patients with subclinical or clinical borderline personality disorder (BPD). These challenges include therapeutic conflicts resulting from harmful drug-drug, and drug-disease interactions. Current guidelines provide no recommendations for concurrent psychotropic and antihypertensive treatment of hypertensive BPD patients who are at even greater cardiovascular risk.

METHODS

We conducted a systematic literature review to assess the extent of available evidence on prevalence rates, cardiovascular risk factors, therapeutic conflicts, and evidence-based treatment recommendations for patients with co-occurring hypertension and BPD. Search terms were combined for hypertension and BPD in PubMed, MEDLINE, EMBASE, Cochrane, and PsycINFO databases.

RESULTS

We included 11 articles for full-text evaluation and found a very high prevalence of hypertension and substantial cardiovascular risk in studies on co-occurring BPD and hypertension. However, we identified neither studies on harmful drug-drug and drug-disease interactions nor studies with treatment recommendations for co-occurring hypertension and BPD.

CONCLUSIONS

Increased prevalence of hypertension in BPD patients, and therapeutic conflicts of psychotropic agents strongly suggest careful evaluation of treatment strategies in this patient group. However, no studies or guidelines recommend specific therapies or strategies to resolve therapeutic conflicts in patients with hypertension and BPD. This evidence gap needs attention in this population at high risk for cardiovascular disease.

Cofactors and comorbidities of necrobiosis lipoidica: analysis of the German DRG data from 2012

BACKGROUND

Necrobiosis lipoidica (NL) is a rare granulomatous inflammatory skin disease of unknown pathophysiology. Its potential association with diabetes mellitus is well known. Other relevant cofactors and comorbidities are subject to controversial debate.

PATIENTS AND METHODS

DRG (diagnosis-related groups) data of all inpatients with a coded primary or secondary diagnosis of NL treated at German hospitals in 2012 were evaluated.

RESULTS

Data of 262 inpatient cases with the primary or secondary diagnosis of NL were analyzed. Women (63.4%; n = 166) were nearly twice as frequently affected as men (36.2%; n = 96). Most NL patients (14.8%) were in the age group between 50 and 55 years. Among comorbidities included in the metabolic syndrome complex, diabetes mellitus was the most common (34.4%; IDDM 20.6%, NIDDM 13.8%), while essential hypertension was observed in 9.2%, obesity in 4.6%, chronic heart failure in 4.1%, and dyslipidemias in 2.3% of cases. Leg ulcers were diagnosed in 7.3% of individuals; other venous disorders, in 5.7%.

CONCLUSIONS

Our data analysis describes one of the largest compilations of patient cases with the diagnosis of NL worldwide. Besides the well-known association with diabetes mellitus, there are numerous other potentially relevant cofactors and comorbidities that should be considered in the diagnosis and management of NL patients.