Guest Editorial: For tonight's Residency Insight, Dr. Sarah Fitzgerald, medical director at the Hess Lower Extremity Wound Care Center in Harrisonburg, Virginia, presents the conclusion of this interesting case of a 25-year-old male who presents with unusual lesions along his bilateral lower extremities.

We received many great responses regarding the case presented in last week’s Residency Insight regarding the 25-year-old male with recurrent abscess formation and lower extremity skin lesions.  You can follow this link to the eTalk thread on this topic to view comments.

     —Ryan Fitzgerald, DPM, PRESENT RI Associate Editor

Case Conclusion: 25 y/o with Recurrent Abscess Formation
and Skin Lesions

Dr. Sarah Fitzgerald Medical Director Hess Lower Extremity Wound Center Harrisonburg, Va

In this case, the patient was taken to the operating room and an incision and drainage of the superficial abscesses were performed. During this procedure, fatty necrosis was observed. Deep wound cultures were obtained, as well as 4mm punch biopsies from the periphery of the skin plaques as well as centrally, and these were sent for pathological analysis.  Local wound care was initiated post-operatively while awaiting the final pathology and microbiology reports.  Pain, which was an issue, was managed with the use of opioid analgesia. While the patient reported some relief following the I&D, he did related a significant amount of continuing pain.

The final microbiology report covering aerobic, anaerobic, fungal and acid fast stain demonstrated “No Growth” at forty-eight hours, consistent with a sterile abscess.  The histopathology report was far more interesting, and demonstrated “granulomas arranged in a layered fashion with evidence of collagen degeneration.  There is evidence of multinucleated lymphocytes, plasma cells, and eosinophils. Additionally noted is thickening of the blood vessel walls and endothelial cell, with swelling found in the middle to deep dermis.”

The histopathology demonstrated findings consistent with the diagnosis of Necrobiosis Lipoidica.  Accordingly, the patient was placed on topical steroid therapy and was referred to a local dermatologist for intralesional steroid injection and further systemic treatment.

DISCUSSION: Necrobiosis Lipoidica (NL)

First described in 1929 by Oppehhein, necrobiosis lipoidica diabeticorum was originally called dermatitis atrophicans lipoidica diabetica, but it was later renamed necrobiosis lipoidica diabeticorum (NLD) by Urbach in 1932.  It was later, in 1935, that Goldsmith reported the first case of similar lesions in a nondiabetic patient. Numerous other authors also began to describe this condition in nondiabetic patients, and a renaming of this disorder was suggested to exclude diabetes from the title. Today, the term necrobiosis lipoidica (NL) is used to encompass all patients with the same clinical lesions regardless of whether or not diabetes is present.

Commonly, these patients present with asymptomatic shiny patches that slowly enlarge over time. Often, these patches usually appear red-brown initially and progress to yellow, depressed atrophic plaques. Ulcerations can occur typically after trauma and occasionally present with associated pain. The clinical appearance of necrobiosis lipoidica is distinctive, yet there are many atypical presentations and early forms can be hard to recognize.

To make the diagnosis, clinical and histopathology findings are paramount. Generally speaking laboratory data is not helpful, although some authors advocate checking for glucose intolerance to identify the presence of diabetes mellitus, as NL has occasionally been shown to be an early sign of the disease.

Histopathologically, necrobiosis lipoidica presents with interstitial and palisaded granulomas that involve the subcutaneous tissue and dermis with a reduction in the number of intradermal nerves and a thickening of the blood vessel walls and endothelial cell swelling. In nondiabetic patients, the vascular changes are not as prominently noted.

TREATMENT:

A review of the literature demonstrates a variety of treatment modalities to attempt to manage this challenging dermatological condition. Numerous authors have described the use of topical and intra-lesional steroids, and studies demonstrate some efficacy of this modality in early stages. However, skin atrophy can occur. Other pharmacological attempts have been made with the goals to reduce morbidity and to prevent complications. Among these, hemorheologic, antiplatelet, antihyperlipidemic, and leprostatic agents as well anticoagulants and retinoids have been described and have demonstrated some success.

Overall, the prognosis of necrobiosis lipoidica from a cosmetic standpoint is poor. Treatment is helpful in halting the expansion of individual lesions, which tend to run a chronic course. As in the case described above, lesional ulcerations and abscess formation can cause significant morbidity requiring prolonged wound care. These ulcerations can be painful, become infected, and heal with scarring.

• Rollins TG, Winkelmann RK. Necrobiosis lipoidica granulomatosis. Necrobiosis lipoidica diabeticorum in the nondiabetic. Arch Dermatol. Oct 1960;82:537-43.
• Lim C, Tschuchnigg M, Lim J. Squamous cell carcinoma arising in an area of long-standing necrobiosis lipoidica. J Cutan Pathol. Aug 2006;33(8):581-3
• Miller RA. The Koebner phenomenon. Int J Dermatol. May 1982;21(4):192-7.
• Ullman S, Dahl MV. Necrobiosis lipoidica. An immunofluorescence study. Arch Dermatol. Dec 1977;113(12):1671-3.
• Clayton TH, Harrison PV. Successful treatment of chronic ulcerated necrobiosis lipoidica with 0.1% topical tacrolimus ointment. Br J Dermatol. Mar 2005;152(3):581-2.
•  Stanway A, Rademaker M, Newman P. Healing of severe ulcerative necrobiosis lipoidica with cyclosporin. Australas J Dermatol. May 2004;45(2):119-22

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