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A pretibial skin lesion in a patient with type 1 diabetes mellitus

Published:January 10, 2022DOI:https://doi.org/10.1016/j.ejim.2022.01.002

      1. Case description

      A 17-years-old woman with type 1 diabetes mellitus known since the age of 9 was admitted in the high-dependency unit for diabetic ketoacidosis. She had a history of poor glycemic control and many previous hospitalizations. Two years earlier, she reported the appearance of a red-brown, telangiectatic and hyperpigmented patch, localized in the pretibial skin of her left leg (Fig. 1). The lesion was well-circumscribed with erythema at the periphery. Two months before a spontaneous ulceration appeared in the middle of the lesion, apparently without any trauma. No other lesions were present all over the body. She denied pain, pruritus or burning sensation. Patient voluntary discharged from the hospital, for this reason it was not possible to continue the diagnostic testing with the biopsy of the lesion. After about three months we contacted the patient again. During this time, she started a successful treatment with topical corticosteroids. The greatest outcome was a fast epithelization and clarification of the lesion (Fig. 2).
      Fig 1
      Fig. 1Pretibial skin lesion of the left leg.
      Fig 2
      Fig. 2Pretibial skin lesion after treatment with topical corticosteroids.

      2. Discussion

      Necrobiosis lipoidica (NL) is a rare, chronic granulomatous dermatitis. Skin involvement usually begins with red-brown or violaceous papules, plaques, or nodules and rapidly progresses to yellow-brown, atrophic, telangiectatic plaques. It usually presents on the lower extremities, especially on the pretibial area. Ulceration is a common complication (10–20% of patients). NL primarily affects young and middle-aged adults, more frequently women.
      NL is strongly but not necessary associated with diabetes mellitus and can precede the diagnosis of this condition (the prevalence of NL among diabetic patients is estimated to be 0.3 - 1.2%). The etiology is unclear, probably it is a consequence of diabetic microangiopathy secondary to deposition of glycoproteins in blood vessels. [
      • Tong Lana X
      • Penn Lauren
      • Meehan Shane A
      • Kim Randie H
      Necrobiosis lipoidica Dermatol.
      ] Nevertheless, glucose control does not appear to correlate with disease activity. Patients are usually asymptomatic, but sometimes they report pruritus or dysesthesia at the site of skin injury. Histological findings demonstrate zones of necrobiosis of collagen with a surrounding inflammatory infiltrate, composed by histiocytes, multinucleated giant cells, lymphocytes and plasma cells. [

      Adam S Richardson, Eric W Hossler Necrobiosis lipoidica diabeticorum Cutis. 2015 May;95(5):252, 265–6.

      ] Histologically it can be difficult to distinguish necrobiosis lipoidica from other non-infectious granulomatous disorders so clinical evaluation still has a fundamental role in the diagnosis. Standard treatment consists of topical or intralesional corticosteroids but it does not always show satisfactory results. Topical tacrolimus and photochemotherapy have been used as second line. [
      • Ginocchio Luke
      • Draghi Lisa
      • Darvishian Farbod
      • Ross Frank L
      Refractory ulcerated necrobiosis lipoidica: closure of a difficult wound with topical tacrolimus.
      ] Spontaneous remission is reported in about 20% of patients.

      References

        • Tong Lana X
        • Penn Lauren
        • Meehan Shane A
        • Kim Randie H
        Necrobiosis lipoidica Dermatol.
        Online J. 2018; 24 (Dec 1513030/qt0qg3b3zw)
      1. Adam S Richardson, Eric W Hossler Necrobiosis lipoidica diabeticorum Cutis. 2015 May;95(5):252, 265–6.

        • Ginocchio Luke
        • Draghi Lisa
        • Darvishian Farbod
        • Ross Frank L
        Refractory ulcerated necrobiosis lipoidica: closure of a difficult wound with topical tacrolimus.
        Adv Skin Wound Care. 2017; 30 (Oct): 469-472https://doi.org/10.1097/01.ASW.0000521867.98577.a5