Necrobiosis lipoidica diabeticorum

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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171 Necrobiosis lipoidica diabeticorum

Instruction

Look at this patient’s legs.

Examine this patient’s back.

Salient features

History

• History of diabetes (according to a recent study from Ireland only a minority of the patients have diabetes; Br J Dermatol 1999;40:283–6).

Examination

• Usually seen in females (two to four times more frequently than in men)

• Sharply demarcated oval plaques seen on the shin (Fig. 171.1), arms or back

• The plaques have a shiny surface with yellow waxy atrophic centres and brownish red margins with surrounding telangiectasia.

image

Fig. 171.1 Necrobiosis lipoidica diabeticorum. Well-demarcated, waxy erythematous plaques with prominent telangiectasias.

Proceed as follows:

• Tell the examiner that you would like to check the urine for sugar.

Diagnosis

This patient has plaques with yellow waxy centres on the shins (lesions) caused by diabetes mellitus (aetiology); the lesions are cosmetically disfiguring (functional status).

Remember: In necrobiosis lipoidica diabeticorum, although the shins, ankles and feet are typically affected, 15% of patients may have lesions elsewhere.

Advanced-level questions

What is the histology of these lesions?

Microscopical studies have shown that it is a disorder of collagen degeneration characterized by a granulomatous response (surrounded by epithelioid and giant cells), thickening of the walls of blood vessels and fat deposition. The exact cause is unknown. Necrobiosis lipoidica diabeticorum may be an antibody-mediated vasculitis with secondary collagen degeneration or the microangiopathy of diabetes (but it is not correlated with the extent of glucose control).

What may complicate it?

Ulceration of the plaque.

What treatment is available for such lesions?

• Good diabetic control

• Whirlpool therapy, occlusive dressings, aspirin, pentoxifylline

• Local steroids.

• Excision and skin grafting

• Hyperbaric oxygen (Diabetes Metab 1998;24:156–9).

Flare-ups are frequent. No treatment is completely effective.

What other skin lesions are usually seen on the shins?

• Erythema nodosum (p. 665)

• Pretibial myxoedema (p. 521)

• Diabetic dermopathy

• Erythema ab igne (p. 599)

• Livedo reticularis.

What are the other skin lesions seen in diabetes?

• Granuloma annulare

• Chronic pyogenic infections and carbuncles (indicating poor control)

• Eruptive xanthomata (from hypertriglyceridaemia associated with poor glycaemic control) (p. 625)

• Xanthelasmata (p. 615)

• Lipoatrophy and lipohypertrophy (p. 609)

• Leg ulcers and gangrene

• Acanthosis nigricans (p. 605)

• ‘Pebbles’ on the dorsal aspect of the fingers (Postgrad Med 2000;107:207–10)

• Peripheral anhydriosis (from autonomic neuropathy)

• Vulval candidiasis.

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