Necrobiosis lipoidica

Created: 7th March 2015 | Last Updated: 15th December 2016

Introduction

Necrobiosis lipoidica is an uncommon skin condition characterised by sharply demarcated, atrophic yellowish patches or plaques on the shins. It was first described in patients with insulin-dependent diabetes but it can affect non-diabetics as well.

This chapter is set out as follows:

Aetiology
History
Clinical findings
Images
Investigations
Management

Aetiology

Vascular changes may play a role
Necrobiosis lipoidica is associated with diabetes, the reasons remain unclear

History

Necrobiosis lipoidica has a gradual onset
Although necrobiosis lipoidica can affect any age, it most commonly presents in young adults and early middle age. Patients with insulin-dependent diabetes tend to present at an earlier age when compared to non-insulin-dependent patients
Females are affected more than males in a 3:1 ratio
In many cases lesions are asymptomatic, although some patients experience pain
The main complaint is the unsightly appearance of the lesions

Clinical findings

Distribution
- Lesions typically affect both shins, although necrobiosis lipoidica is sometimes unilateral and other sites can be affected
Morphology
- Typically, one or more yellowish patches / plaques
- Lesions grow with an erythematous edge, and a centre that becomes shiny and atrophic with prominent telangiectasia
- Ulceration can occur
- Slow expansion over many years is usual, although lesions may go through periods of being more, and less, active

Images

Please click on images to enlarge, or choose to download. Images must only be used for teaching purposes and are not for commercial use. Notice and credit must be given to the PCDS and any other named contributor.

Download	Figure: 1 Necrobiosis lipoidica A very characteristic lesion with a yellowish colour, a red leading edge, and central atrophy with telangiectasia
Download	Figure: 2 Necrobiosis lipoidica An early lesion, characteristic colours
Download	Figure: 3 Necrobiosis lipoidica An early lesion with characteristic features, including an erythematous leading edge
Download	Figure: 4 Necrobiosis lipoidica An early lesion, as yet not showing all of the characteristic features
Download	Figure: 5 Necrobiosis lipoidica - both shins The patch of the left leg has become hyperkeratotic (scaly)
Download	Figure: 6 Necrobiosis lipoidica White atrophic centre
Download	Figure: 7 Necrobiosis lipoidica - ulcerated
Download	Figure: 8 Necrobiosis lipoidica with a healed ulcer
Download	Figure: 9 Necrobiosis lipoidica with extensive ulceration
Download	Figure: 10 Necrobiosis lipoidica Central atrophy, telangiectasia, a healed ulcer, and an erythematous edge
Download	Figure: 11 Sarcoidosis Cutaneous sarcoid presents in many ways, and can mimic numerous conditions

Investigations

It is important to investigate for diabetes mellitus
The diagnosis is usually clinical, although sometimes a biopsy is needed if the presentation is atypical as cutaneous sarcoid can mimic necrobiosis lipoidica

Management

Step 1: general measures

Provide a patient information leaflet
Smoking cessation may help
Due to the increased risk of ulceration, advise the patient to avoid traumatising the skin
Not all cases require treatment

Step 2: topical steroids

A decision to treat necrobiosis lipoidica needs careful discussion with the patient - at best, individuals can expect a mild-moderate improvement, and one has to weigh up the possible risks of steroid atrophy
If treatment is given use a potent topical steroid, eg 0.1 % betamethasone cream (or ointment) once a day, and advise application only to the leading inflammatory edge and not the atrophic centre. The effectiveness of treatment can sometimes be enhanced by using occlusion eg Clingfilm
Photograph the lesion / lesions and review three months after starting the treatment to assess response

Step 3: steroid sparing therapy

If there are concerns with regards to steroid atrophy, consider a trial of 0.1% tacrolimus ointment BD

Step 4: ulcerated lesions

Consider treating more aggressively, for example:
- 0.1% betamethasone cream (or ointment) under Viscopaste ® bandages, changed once a week
- Dermovate ® cream (or ointment) once a day and tacrolimus 0.1% ointment at the other end of the day
- Again, photographs are useful to monitor progress

Step 5: Secondary Care

Patients with troublesome, recalcitrant lesions, especially if ulcerated, should be referred to Dermatology
One of the most effective treatments is the careful administration of intralesional steroids in to the expanding edge
Many treatments have been tried for more severe cases of necrobiosis lipoidica, including PUVA (phototherapy) and ciclosporin, however there is limited evidence for their effectiveness
Occasionally a chronic, ulcerated lesion can transform in to a squamous cell carcinoma. Refer suspect lesions urgently as a 2 Week Rule