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What is Necrobiosis Lipoidica Diabeticorum?

The name sounds complex, but on examination it gives a hint about which disease it’s most associated with. Necrobiosis lipoidica diabeticorum (NLD), is a rash that occurs on the lower legs. It is more common in women, and there are usually several spots.

NLD usually occurs more often in people with diabetes; in people with a family history of diabetes; or those with a tendency to get diabetes. Still, the exact cause of NLD in not known. A similar condition that is often confused with it is granuloma annulare. Similar to the association of NLD and diabetes, it appears that a high percentage of persons with disseminated granuloma annulare have diabetes mellitus.

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Signs and Symptoms

It most frequently appears on the patient’s shins, generally on both legs, although it may also occur on other areas, including surgical sites. The lesions by and large tend to be
asymptomatic, but may become tender and ulcerate when injured. The first symptom of it is usually a bruised appearance, which is not necessarily associated with a known injury. The extent to which it is inherited is unknown.

A hardened, raised area of the skin, the center of it usually has a yellowish tint. However, in contrast, the surrounding area surrounding is a dark pink. It is possible for the affected areato spread, or turn into an open sore. When this happens, the patient is at greater risk of developing ulcers. If an injury to the skin occurs on the affected area, it may not heal properly, or it will leave a dark scar.

 

Differential Diagnosis

Usually the appearance is fairly typical but variations can be difficult to diagnose. Therefore a skin biopsy is needed for diagnosis. Without biopsy testing, it can appear to look like the following:Spots associated with NLD

-Yellow, fatty lesions resembling xanthoma.
-Superficial annular lesions that look like granuloma annulare. However, granuloma annulare do not exhibit the typical yellow fatty appearance of    necrobiosis lipoidica plaques.
Sarcoidosis,which can appear very similar, even on histology.
Erythema nodosum,which are lesions that do not ulcerate.
-Rheumatoid nodules, that are similar histologically, but tend to be raised rather than be atrophic. Ulcerated necrobiotic areas have been described  in rheumatoid arthritis.
Varicose eczema, which produce a scaly rash and is usually near the malleoli.

Treatment

It is impaired by lack of understanding of the aetiology of the condition. No treatment to date is completely effective and, whilst numerous types have been tried, none has proven effectiveness based on controlled trials. The following represent a range of possible options:

-Strategies for prevention of ulcers, but trauma should be avoided. Wound care for established ulcers is as obtains for other diabetic ulcers.
-Potent topical steroids are usually considered first-line treatment. This may reduce inflammation, but it does not benefit burned-out lesions. They may aggravate atrophy, so careful monitoring is required.
-Intralesional injections of steroids are also sometimes helpful, but the risk of ulceration could increase.
-Immunomodulating drugs; however, these have varying levels of success.
-Antiplatelet treatment seems logical, but controlled trials have had different results.
-Excision and grafting (used occasionally), but poor healing and recurrence are common.
-Phototherapy, that is, photodynamic therapy.
-Laser treatment for stabilisation of lesions, and reduction of bruising and spider veins.

Studies have revealed spontaneous healing of necrobiosis lipoidica following pancreas and kidney transplantation. Under these circumstances, the thinking is that the immunosuppressive regime plays a significant role.

Photodynamic Therapy Treatment

NLD usually goes through stages of activity and inactivity. Therefore, one is not able to predict when the condition will flare. Ultraviolet light treatment has been found to be useful to control flares. A baby aspirin each day, and other medications that thin the blood, may help too. Other medications, including prednisone pills (steroids) are used in difficult or severe cases. Because of the unpredictability of the condition, it is advised that you only act on the advice of your doctor.

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