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 Mimicking Cutaneous Sarcoidosis Finally Treated With an Intralesional Injection of Corticosteroid: A Case Report

BACKGROUND: Necrobiosis lipoidica (NL) and sarcoidosis are granulomatous disorders with an unknown pathogenesis. They may coexist in the same patient, which suggests a possible overlap between these diseases among shared granulomatous inflammatory pathways. Case Presentation: This study presents the case of a non-diabetic 52-year-old woman who presented with red-yellowish border plaques on the face and upper extremities previously diagnosed as sarcoidosis. After 13 years of inappropriate treatment, histopathological findings consistent with the clinical and para-clinical examination suggested the diagnosis of NL. After treatment with an intralesional injection of steroids, significant improvement was observed, and no recurrent lesions were found. CONCLUSION: Necrobiosis lipoidica may mimic cutaneous sarcoidosis. Prompt recognition and treatment of NL can be helpful for managing the disease. J Drugs Dermatol. 2020;19(1):92-94. doi:10.36849/JDD.2020.4675

Necrobiosis lipoidica

We present a case of necrobiosis lipoidica (NL) of the right abdomen in a 75-year-old man. A skin biopsy performed showed a layered infiltrate of mono and multinucleated histiocytes palisaded around degenerated collagen bundles. Laboratory workup was unremarkable. The patient was treated with topical corticosteroids with cessation of progression of his disease, although the eruption did not resolve. There are a number of treatments for NL reported in the literature, all with varying efficacy. Although NL lesions are usually asymptomatic, patients with NL must be monitored closely for signs of ulceration or malignant transformation, in which case more aggressive treatment options may be warranted.

An atrophic plaque on the breast six years after breast reconstruction surgery

Necrobiosis lipoidica (NL) is a cutaneous disease entity that typically manifests as atrophic yellow plaques with telangiectasias on the anterior tibial region. Although NL is commonly associated with diabetes mellitus, the role of trauma in disease development is less commonly emphasized. The relationship between NL and the Köbner phenomenon has been established, as a few cases of NL occurring in surgical scars have been reported in the literature. We report the first case of NL occurring in a mastectomy scar on the breast in a non-diabetic female, and explore the relationship between NL, diabetes mellitus, and trauma.

Necrobiosis lipoidica

BACKGROUND

Necrobiosis lipoidica presents with a distinctive appearance making it an important clinical diagnosis.

OBJECTIVE

To describe a case of necrobiosis lipoidica in a patient with type 1 diabetes mellitus, and to discuss differential diagnoses and management.

DISCUSSION

Necrobiosis lipoidica is most commonly found on the shins, presenting as a well-defined plaque. Management is challenging and options are discussed. Avoiding ulceration is a key concern.

Necrobiosis lipoidica diabeticorum: necrobiosis lipoidica diabeticorum in a Nigerian from the north. A case report

BACKGROUND

Necrobiosis lipoidica is a rare complication of diabetes mellitus.It is said to occur more often in people with diabetes,a family history of diabetes,tendency to develop diabetes mellitus and those with insulin dependent diabetes.

METHOD

We report an evaluated case of necrobiosis lipoidica diabeticorum residing in the northern part of Nigeria.

RESULT

The patient was treated for 3 weeks in the hospital on admission and was followed up in the general-out-patient department (GOPD) and has been in good health.

AIM AND OBJECTIVE

To bring to the fore of clinicians this dermal complication of diabetes mellitus, the different medical treatments available and the medical treatment employed in our index patient.

CONCLUSION

That necrobiosis lipoidica diabeticorum does exist in our environment and requires a high index of suspicion and scrupplelousness in making the diagnosis and treating the patient.

[Lipoid necrobiosis in the practical work of a therapist and dermatologist]

This paper deals with the main aspects of etiology and pathogensis, clinical picture and therapy of lipoid necrobiosis. A case of successful treatment of the disease that developed long before clinical and laboratory manifestations of disturbed carbohydrate metabolism is reported.

Differential diagnosis of round or discoid lesions

Dermatologists are called on to diagnose a variety of skin conditions in diverse age groups. Dermatologic diagnosis, based on identification of a primary lesion, uses morphologic clues to categorize the pathologic process causing the eruption. In addition, distribution and grouping of lesions helps support a specific diagnosis. Dermatologists consciously or unconsciously use pattern recognition to arrive at their differential diagnosis based on clinical experience and their having previously viewed similarly appearing skin lesions in lectures, texts, and journals. Round and discoid patches and plaques are extremely common in the clinical practice of dermatology. This contribution reviews the dermatologic conditions that present as round or discoid lesions and presents an approach to diagnosis.

[Right-sided lower abdominal pain and diarrhea of a young diabetic woman]

We report the case of a 24-years old diabetic women hospitalised because of right-sided lower abdominal pain and diarrhea. She fulminantly developed shock before appendectomy could be performed and was transferred to intensive care unit. Hypotension remained and laparoscopy revealed primary peritonitis and toxic shock syndrome by Group A Streptococcus which was cultivated in blood and ascites. Therapy with penicilline and clindamycine resolved symptoms. During hospitalisation Clostridium difficile colitis occurred. This complication leaded to prolonged hospitalisation.

[Successful therapy of ulcerated necrobiosis lipoidica non diabeticorum with cyclosporine A]

Necrobiosis lipoidica is an inflammatory granulomatous skin disease of unknown etiology which is associated with diabetes mellitus in about 60% of the patients. In 15-35% of the affected patients painful ulcerations may occur after minimal trauma which can be extremely refractory to therapy. Because of the unknown pathomechanisms, current therapeutic options are limited. We report on a 68-year-old patient with an 18 year history of ulcerated necrobiosis lipoidica non diabeticorum of both lower limbs, which responded to systemic cyclosporine A. Based on this case, we discuss the role of cyclosporine A in patients with necrobiosis lipoidica in the context of the disease etiology.

Periorbital necrobiosis lipoidica diabeticorum: case report

Necrobiosis lipoidica diabeticorum (NLD) is a relatively common manifestation of diabetes mellitus that is thought to be related to immune-complex vasculitis. The legs are the most common site for NLD, but other locations, such as the forearms or hands, have been reported. We describe a case of periorbital NLD that was diagnosed on the basis of histopathology.

Familial necrobiosis lipoidica not associated with diabetes

A 42-year-old woman presented with a 12-year history of extensive yellow and erythematous plaques, round and oblong with irregular configuration and glossy atrophic central areas on the pretibial aspects of both legs. Her 45-year-old sister presented with a 7-year history of a single plaque with erythematous margins, abundant telangiectases, and an atrophic center in the lower portion of the left leg. There was no family history of type-1 or type-2 diabetes mellitus. Both patients had normal fasting glucose concentration, oral glucose tolerance test, and glucose overload test. Different treatment options including topical corticosteroids were unsuccessful. Treatment with oral fumaric acid esters was attempted but the medication was discontinued because of intolerable side effects (flushing and gastrointestinal discomfort). At present, after a follow-up of 2 years, the plaques remain unchanged. These two cases should be added to the few cases of familial nondiabetic necrobiosis lipoidica previously reported.

Necrobiosis Lipoidica

Necrobiosis lipoidica (NL) is a granulomatous condition with a degenerative connective tissue of unknown etiology very often associated with diabetes. Histopathologically, NL involves all of the dermis and, often, the subcutaneous fat produces a septal panniculitis. There are some changes suggesting the diagnosis of NL, and systemic disease should be considered if there is the presence of necrotizing vasculitis in the skin biopsy. Many theories of pathogenesis have been proposed, and many types of drugs are available for use in its treatment.

Epidermoid carcinoma and perforating necrobiosis lipoidica: a rare association

We report the case of a 33-year-old patient who had had insulin-dependent diabetes mellitus (IDDM) since he was 11 months old, and who presented with major perforating necrobiosis lipoidica (PNL) complicated by a well-differentiated epidermoid carcinoma. PNL is a rare clinical form of NL, always associated with diabetes. Only seven cases have been reported to date in the literature, and to the best of our knowledge, an association of epidermoid carcinoma and PNL has never been described. The development of a tumoral transformation on a classical NL plaque has only been described 12 times. The presence of an epidermoid carcinoma on a weakened background with permanent ulceration suggests that early surgical excision of the tumour and of the NL followed by a skin graft might be the treatment of choice. Radiotherapy seems to be a poor therapeutic option.

Necrobiosis lipoidica of the glans penis

We report a 65-year-old diabetic man with necrobiosis lipoidica occurring on the glans of penis. He was initially seen with chronic ulcerative balanitis that eventually healed with strict control of diabetes mellitus, cystostomy, and pentoxifylline, leaving heavily depressed scars. Penile necrobiotic palisading granulomas include necrobiosis lipoidica and granuloma annulare. On the basis of the literature review, these 2 diseases manifest different skin lesions.

[Vacuum therapy in a pre- and postsurgical ulcera crurum]

Chronic wounds are often a diagnostic as well as a therapeutic problem. Three case reports depi important differential diagnoses. The importance and efficacy of vacuum assisted closure in a presurgical treatment as well as after mesh graft transplanation will be described.

[Necrobiosis lipoidica. Report of 4 cases and review of the literature]

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.

Two girls with necrobiosis lipoidica and type I diabetes mellitus with transfollicular elimination in one girl

Necrobiosis lipoidica (NL) is a rare disorder that usually appears in the lower extremities and it is often related with diabetes mellitus (DM). There are few reported cases of NL in children. Transfollicular elimination of necrotic material has been described in adult patients with NL diabeticorum. Here we describe two new cases of NL in two girls with type I diabetes mellitus (DM). One of the cases is the first case, to our knowledge, of transfollicular elimination in a girl. The other case is the second case reported of lesions on the arms in a child with DM.