Squamous cell carcinoma arising in long-standing necrobiosis lipoidica

Necrobiosis lipoidica (NL) is a disease of collagen. Squamous cell carcinomas developing in areas of chronic ulceration and scarring have been well documented in a variety of skin diseases but rarely in areas of necrobiosis lipoidica. The case history of a 76-year-old female is presented, whose squamous cell carcinoma appeared 30 years after the diagnosis of necrobiosis lipoidica. The clinical and histopathological picture is described, stressing the importance of the unusual association of the two pathologies in the prognostic.     

Squamous cell carcinoma arising in an area of long-standing necrobiosis lipoidica

BACKGROUND: Squamous cell carcinoma in an area of chronic ulceration is a well-documented phenomenon. However, its occurrence arising de novo in an area of necrobiosis lipoidica is rare. METHOD: We report a case in a 53-year-old female who presented with a 2 month history of an erythematous nodule occurring in a plaque of necrobiosis lipoidica on the medical aspect of the right lower leg. She had a background of poorly controlled Type 1 diabetes. RESULTS: Histopathological findings revealed a well-differentiated squamous cell carcinoma overlying an area of necrobiosis lipoidica. Treatment was by excision and split-thickness skin graft. CONCLUSION: Clinicians should be aware of malignant transformation within a plaque of necrobiosis lipoidica. Early detection will allow conservative treatment.     

Necrobiosis lipoidica and sarcoidosis

We report the case of a female patient with necrobiosis lipoidica of the lower legs and coexistent systemic and cutaneous sarcoidosis. We review the six previously reported patients with coexisting necrobiosis lipoidica and sarcoidosis. The associations between the granulomatous disorders of the skin, especially necrobiosis lipoidica, sarcoidosis and granuloma annulare, are discussed. The common pathogenetic features of these disorders are reviewed.     

Simultaneous occurrence of ulcerated necrobiosis lipoidica and granuloma annulare in a patient: case report

Simultaneous occurrence of granuloma annulare and necrobiosis lipoidica is quite rare. There are seven reported cases in the literature, but only one presenting ulcerated necrobiosis lipoidica. We report a 39-year-old male with histopathologically confirmed granuloma annulare and ulcerated necrobiosis lipoidica, without diabetes mellitus.     

Coexistence of sarcoidosis and necrobiosis lipoidica of the legs—A report of two cases

Two patients are reported with systemic sarcoidosis and necrobiosis lipoidica on the legs. There are no previous reports of this association. In view of the relative rarity of these two diseases, there is a clear suggestion of a pathogenetic link between sarcoidosis and necrobiosis lipoidica. Therefore, in patients with necrobiosis lipoidica the possibility of systemic sarcoidosis should be borne in mind and appropriate investigations should always be carried out.     

Ulceration in necrobiosis lipoidica—a case report and study

A case of aggressive ulceration of necrobiosis lipoidica was successfully treated with oral prednisolone. A retrospective study of 23 cases of necrobiosis lipoidica revealed a 13% incidence of ulceration. The pathogenesis, clinieal features and treatment of ulceration in necrohiosis lipoidica are discussed.     

Necrobiosis lipoidica diabeticorum: a clinicopathologic study

Necrobiosis lipoidica diabeticorum is an unusual dermatologic condition with a characteristic clinical appearance and a clear association with diabetes mellitus. There is currently no treatment that reverses the atrophic changes associated with this lesion. We have carried out a clinicopathologic study on 15 subjects and, in addition, have reviewed 10 further biopsy specimens of necrobiosis lipoidica diabeticorum. We found a frequent association of necrobiosis lipoidica diabeticorum with other chronic complications of diabetes mellitus, including limited joint mobility. It is possible that nonenzymatic glucosylation or other changes in collagen may be important in the etiology of necrobiosis lipoidica diabeticorum and the limited joint mobility. We confirmed that cutaneous anesthesia is usually present in the necrobiosis lipoidica diabeticorum lesions. With the use of an antibody to S100 protein and an immunohistochemical method, there was an apparent decreased number of nerves in the skin lesions. We suggest that sensory loss results from local destruction of cutaneous nerves by the inflammatory process. Finally, in six elliptical biopsies extending into clinically normal skin, we demonstrated that the inflammatory infiltrate of necrobiosis lipoidica diabeticorum extended from the lesion into apparently normal skin surrounding clinically active lesions. Thus, intradermal steroids might be administered to perilesional areas surrounding active lesions in the hope of halting progression.     

Links Between Granuloma Annulare,Necrobiosis Lipoidica Diabeticorum and Childhood Diabetes: A Matter of Time?

Abstract: Diabetes mellitus is associated with a range of dermatologic presentations, including granuloma annulare and necrobiosis lipoidica diabeticorum. Granuloma annulare occurs earlier than necrobiosis lipoidica diabeticorum and the association with diabetes mellitus is much weaker. We describe two children with diabetes who both developed granuloma annulare and later, necrobiosis lipoidica diabeticorum. We postulate that the early onset and transient nature of granuloma annulare, compared with the later onset and persistence of necrobiosis lipoidica diabeticorum, might account for the different apparent rates of association with diabetes mellitus.     

Necrobiosis lipoidica: a case with prominent cholesterol clefting and transepithelial elimination

Transepithelial elimination of degenerated collagen through the hair follicle in necrobiosis lipoidica is rare, clinically manifesting as comedo-like plugs. Also unusual in necrobiosis lipoidica is the finding of cholesterol cleft formation. We report a case of necrobiosis lipoidica with transepithelial elimination of cholesterol crystals through hair follicles. This has been described in necrobiotic xanthogranuloma, demonstrating some overlap in the histopathologic findings in both necrobiotic granulomas. Additional criteria should be used to establish the diagnosis.     

Transcutaneous measurement of oxygen and carbon dioxide pressure in necrobiosis lipoidica

Transcutaneous measurement of oxygen pressure (PcO2) and carbon dioxide pressure (PcCO2) was performed in nine patients with histologically confirmed necrobiosis lipoidica. None of the patients had diabetes mellitus. All measurements were taken at the lower leg. In each case, the atrophic center, the inflamed border, and the surrounding clinically normal skin of necrobiosis lipoidica were examined at 44 degrees C sensor temperature (maximal vasodilatation). Statistically significant hypoxia was found in the area of necrobiosis lipoidica, which was even more pronounced in the inflamed border. Inhalation of 100% oxygen provoked a marked increase in the PcO2 in the lesion, but the values were still significantly lower than in the normal skin. At the edge of the lesions the PcCO2 was significantly elevated. These findings support a vascular origin of necrobiosis lipoidica, involving reduced vascular perfusion combined with diffusion block.     

Serum alpha 2 globulin levels in granuloma annulare and necrobiosis lipoidica

Alpha 2-macroglobulin, caeruloplasmin and haptoglobin were measured in the sera of patients with necrobiosis lipoidica, granuloma annulare and diabetes. Alpha 2 Macroglobulin and caeruloplasmin were significantly raised in diabetes, and caeruloplasmin was raised in necrobiosis lipoidica without diabetes. The ratio of alpha 2-globulin to serum albumin was significantly high for all three proteins in diabetes, and for haptoglobin and caeruloplasmin in necrobiosis lipoidica. None of these proteins was abnormally raised in non-diabetic patients with granuloma annulare. There is good evidence that the plasma protein changes in diabetes contribute to the development of microangiopathy by their influence on blood viscosity. The altered plasma protein profile in necrobiosis lipoidica may therefore be of relevance to the development of the vascular lesions in this disorder.     

Expression of the human erythrocyte glucose transporter Glut-1 in areas of sclerotic collagen in necrobiosis lipoidica

BACKGROUND: Glut-1 is the human erythrocyte glucose transporter which mediates facilitative transport of glucose across epithelial and endothelial barrier tissues. A primary abnormality in glucose transport and Glut-1 cell-surface content has been observed in fibroblasts from NIDDM and obese individuals. With the strong correlation between necrobiosis lipoidica and diabetes mellitus, we investigated the expression of Glut-1 in diabetic individuals with necrobiosis lipoidica (NL). METHODS: A polyclonal anti-Glut-1 antibody was used with a standard immunoperoxidase technique to determine Glut-1 expression by fibroblasts in areas of sclerotic collagen from specimens taken from diabetic individuals with necrobiosis lipoidica,and non-diabetic individuals with scars and granuloma annulare (GA). RESULTS: Our results showed Glut-1 expression in the areas of sclerotic collagen in patients with NL, possibly contributing to insulin resistance in these tissues. CONCLUSIONS: Our findings raises the question as to whether abnormalities in glucose transport by fibroblasts in individuals with necrobiosis lipoidica contribute to the histopathologic changes.     

Epidermal dendritic S100 positive cells in necrobiosis lipoidica and granuloma annulare

Using an antibody to S100 protein, the number of dendritic cells above the basal layer in the epidermis was assessed in necrobiosis lipoidica and granuloma annulare. A statistically significantly higher number of these cells was found within the epidermis in necrobiosis lipoidica compared with granuloma annulare and normal skin. The numbers were similar to those seen in sarcoidosis and tuberculous reactions in the skin, which raises the possibility of an immune pathogenesis for necrobiosis lipoidica.     

Ulcerative necrobiosis lipoidica responsive to colchicine

Necrobiosis lipoidica is an uncommon granulomatous disease of unknown aetiology. Few treatments have emerged with consistent efficacy and the ulcerated form of necrobiosis lipoidica can be particularly difficult to treat. A 56‐year‐old non‐diabetic woman with chronic ulcerative necrobiosis lipoidica unresponsive to other therapies was commenced on colchicine treatment. Complete resolution of the ulcers was observed after 2 months therapy with colchicine 500 µg twice daily.     

Alterations of connective tissue in granuloma anulare and in necrobiosis lipoidica. Microradiographic studies]

The microradiogram of granuloma anulare was compared with that of necrobiosis lipoidica. In the areas of cellular infiltration, the amount of connective tissue missing depended on the degree of infiltration. Apparently the collagenous bundles were destroyed, not pushed aside. In the necrobiotic type of necrobiosis lipoidica, the damage to collagenous tissue was more severe than one would have expected from the stained sections. The collagenous bundles were generally swollen, and there was a complete lack of normal high-density bundles in the damaged areas, in contrast to granuloma anulare and to the granulomatous type of necrobiosis lipoidica, however, the damage to the collagenous tissue seemed less severe in the microradiograms than in the stained sections. Differences between granuloma anulare and necrobiosis lipoidica were to be found in the microradiogram (see tables), but in general a differential diagnosis is only possible in severe cases, in spite of the different clinical picture.     

Granuloma Annulare, Necrobiosis Lipoidica, and Diabetic Disease

One hundred sixteen patients with granuloma annulare and necrobiosis lipoidica were studied. The relationship of these two disorders with diabetes mellitus suggests that atypical granuloma annulare could be linked to necrobiosis lipoidica, toward which it progresses.     

Necrobiosis lipoidica

A 69-year-old patient presented with different skin lesions all of which belonged to group of necrobiosis lipoidica. The initial histologic diagnosis was actinic granuloma O??Brien. A subsequent biopsy was interpreted as granulomatous necrobiosis lipoidica. The history of these necrobiotic variants is reviewed and exemplarily depicted with this case. Necrobiosis lipoidica is part of the spectrum of granulomatous skin disorders. Although its etiology is unclear, an association with diabetes mellitus is often discussed. Multiple therapeutic options exist, but standardized guidelines for treatment are missing.     

Ulcerating necrobiosis lipoidica effectively treated with pentoxifylline

A 30-year-old man had suffered from persistent ulceration within an area of necrobiosis lipoidica diabeticorum for 13 months. The ulcerating necrobiosis lipoidica was resistant to topical therapy and oral therapy with acetylsa-licylic acid. However, the ulcers healed completely within 8 weeks of administration of 400 mg pentoxifylline twice daily.     

Perforating necrobiosis lipoidica in a girl with type 1 diabetes mellitus: a new case reported

Necrobiosis lipoidica is an idiopathic dermatological condition that is strongly associated with diabetes mellitus. It is more commonly seen in women than men. The average age of onset is 30-40 years. Necrobiosis Lipoidica diabeticorum is an extremely rare finding in childhood diabetes. We describe the case of a 13-year-old girl who has had type 1 diabetes mellitus since she was 8 years old. The patient presented with 2 well-defined, persistent plaques with a depressed central area and elevated purple peripheral ring, one on the right thigh and the other over the lateral left leg. Histopathologic evaluation of the patient's biopsy confirmed the diagnosis of necrobiosis lipoidica with transfollicular elimination. Our patient is the second pediatric case described with perforating necrobiosis lipoidica. We review the literature and discuss clinical features, several complications, and the most recent treatment options for necrobiosis lipoidica in diabetic children.     

Necrobiosis lipoidica over appendectomy scar in a patient with morphea of the breast

Morphea is a sclerosing skin disease that may be clinically confused with a carcinoma when it involves the breast. It has been described in association with earlier radiotherapy and with silicone breast implants. We describe the case of a woman with morphea of the breast who developed necrobiosis lipoidica over the scar of an appendectomy performed 38 years earlier. Necrobiosis lipoidica over surgical scars is infrequently found in the literature. We review the published cases and discuss the association of necrobiosis lipoidica with morphea.