BJD

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Necrobiosis lipoidica (NL) is a burdensome degenerative disorder of collagen that usually affects the legs in those with diabetes mellitus, the prevalence within this population being approximately 0.3–1.2%.¹ It is an inflammatory condition that, if untreated, inevitably results in scarring, and it can have a very negative impact on quality of life. It is not only demoralising by virtue of its unsightly appearance, but also very uncomfortable if it ulcerates, as well as being potentially dangerous given the albeit small risk of squamous cell carcinoma developing within long-standing lesions.

Numerous therapeutic options for NL have been advocated,² including intra-lesional steroid,^3,4 but there is a paucity of randomised controlled trial data regarding their efficacy. We report a case that acted as her own control in demonstrating the effectiveness of intra-lesional steroid injections.

A 19-year-old woman with poorly controlled type I diabetes mellitus, diagnosed five years previously and treated with a combination of rapid and long-acting insulins, presented with the recent onset of a non-ulcerated inflamed plaque proximal to her left medial malleolus. Histological examination of an incisional biopsy confirmed the clinical suspicion of NL, with large foci of necrobiotic granulomas and focal fibrosis within the dermis, surrounded by a chronic inflammatory cell infiltrate.

The lesion was treated with intra-lesional triamcinolone acetonide (10 mg/ mL) in a piecemeal fashion as the patient disliked injections. The upper anterior quadrant was treated first, followed at two-monthly intervals by the lower anterior quadrant and then the posterior half. The benefit of the individual injections was clearly visible (see Figure 1). After six months a small recurrence was noted which was re-treated, and one year later there was no evidence of residual NL. There was initially a minimal loss of tissue substance and a mild sensation of numbness over the treated area, but overall the cosmetic result was excellent and the patient was discharged with photoprotection advice. Serendipitously, she was seen four years later when she attended as a relative, and there had been no recurrence and no clinically apparent scarring.

This case illustrates that intra-lesional triamcinolone is effective in the treatment of early NLD and that the improvement is sustained. We recommend intra-lesional steroid as a well tolerated, easily administered treatment for NL, and suggest that early intervention has the potential to completely obviate the sequelae consequent on scarring.

Editor’s note Necrobiosis is largely a clinical diagnosis and biopsy should be used with caution because of the possibility of ulceration. Perhaps the authors should consider comparing a topically applied strong steroid under occlusion with intralesional administration

References

1. Reid SD, Ladizinski B, Lee K, Baibergenova A, Alavi A. Update on necrobiosis lipoidica: a review of aetiology, diagnosis, and treatment options. J Am Acad Dermatol 2013;69:783–91. https://doi.org/10.1016/j.jaad.2013.05.034

3. Jiquan S, Khalaf AT, Jinquan T, Xiaoming L. Necrobiosis lipoidica: a case with histopathological findings revealed asteroid bodies and was successfully treated with dipyridamole plus intralesional triamcinolone. J Dermatol Treat 2008;19:54–7.

4. Abdulla FR, Sheth PB. A case of perforating necrobiosis lipoidica in an African American female. Dermatology Online Journal 2008; 14(7):10.

Correspondence: Stephanie L Ball
Department of Dermatology, Royal Infirmary of
Edinburgh, Edinburgh EH3 9HA, UK
E-mail: stephanie.ball@nhslothian.scot.nhs.uk

Treatment of necrobiosis lipoidica with intra-lesional glucocorticoid

References