“Written informed consent was obtained from the patient to
publish this report in accordance with the journal’s patient consent
policy”
Dear Editor;
Necrobiosis Lipoidica (NL) is a rare granulomatous skin condition
typically occurring in lower extremities. We report an atypical case of
NL and we highlight the role of dermoscopy in the diagnostic approach.
A 53-year-old lady, presented to our dermatology department with a
3-month history of a painful and pruritic skin lesion on the trunk. She
was known to have diabetes type 2 for the last 5 years, which was under
control with oral antidiabetic agents. There was no history of local
trauma or infection. Dermatologic examination showed an indurated,
erythematous plaque, giving rise to a serous fluide without atrophy,
ulceration or local inflammatory signs. The lesion was localized in the
intermammary area and included the upper inner part of the two breasts(Figure 1a) . Systemic examination was unremarkable, notably no
fever or axillary lymphadenopathies. On dermoscopy, the lesion showed
uniformly distributed linear branched vessels, white linear streaks and
yellow structureless areas (Figure 1b) . Her laboratory tests
were within normal ranges, apart from hyperglycemia and high glycated
hemoglobin test. An Ultrasound scan showed a subcutaneous fat
thickening, with no collection, while mammography was read as normal.
The patient was prescribed a course of antibiotics for ten days without
any improvement. Histological examination of a skin biopsy stained with
hematoxylin and eosine showed sandwich-like horizontal layers of
necrobiotic collagen alternating with inflammatory cell infiltrates of
lymphocytes, histiocytes, multinucleated giant cells and plasma cells.
Stain for acid-fast bacilli was negative. The diagnosis of truncal NL
was made based on clinics, dermoscopic and histological findings. The
patient was treated with potent topical steroids once daily. The skin
lesion gradually resolved within two weeks (Figure 2a,2b) .
NL
is a rare chronic granulomatous dermatitis, which typically affects
young and middle-aged adults. It was described in association with
sarcoidosis, thyroid disorders, inflammatory bowel disorders, but most
frequently with diabetes mellitus (1,2) . NL affects 11% to
87% of diabetic patients (3) . It was described for the first
time by Oppenheim in 1929. Clinically, it is characterized by
well-defined erythematous papules, plaques or nodules. The center of the
plaque may show areas of atrophy and telangiectasia. Later, it may
develop ulceration in around 30% of cases and rarely squamous cell
carcinoma (4) . It is located usually on the leg. Truncal
location, as seen in our patient, is very rare. Only one case was
reported in 2020 (5) . Dermoscopy is a non-invasive tool that is
very helpful in the diagnosis of such atypical cases. Three main clues
are suggestive of NL, notably linear branched vessels, a background of
yellow structureless areas and white linear streaks. Some authors
suggested a correlation between the different stages of the disease and
dermoscopic morphology of vessels, which presents at first as curved
lines, than as linear serpentine vessels and finally as linear branches.
To the best of our knowledge, our observation is the second report of
truncal NL in the literature. It highlights the important role of
dermoscopy in guiding the diagnosis of such atypical clinical
presentations.
- Reid SD, Ladizinski B, Lee K, Baibergenova A, Alavi A. Update on
necrobiosis lipoidica: a review of etiology, diagnosis, and treatment
options. J Am Acad Dermatol. 2013;69 (5):783-791.
- Clinical Features and Comorbidities of Patients with Necrobiosis
Lipoidica with or Without Diabetes. Hashemi DA, Brown-Joel ZO,
Tkachenko E, Nelson CA, Noe MH, Imadojemu S, Vleugels RA, Mostaghimi
A, Wanat KA, Rosenbach M. JAMA Dermatol. 2019;155(4):455.
- O’Toole EA, Kennedy U, Nolan JJ, Young MM, Rogers S, Barnes L.
Necrobiosis lipoidica: only a minority of patients have diabetes
mellitus. Br J Dermatol . 1999;140 (2):283-286.
- Uva L, Freitas J, Soares de Almeida L, Vasques H, Moura C, Miguel D,
Filipe P. Squamous cell carcinoma arising in ulcerated necrobiosis
lipoidica diabeticorum. Int Wound J. 2015 Dec;12(6):741-3.
- M. Alkhatieb, H. Mortada. Truncal necrobiosis lipoidica diabeticorum:
A first case report. international Journal of Surgery Case Reports 77
(2020) 311–313.
Figure 1: a: indurated, erythematous plaque, without atrophy or
local inflammatory signs, b: red arrow: linear branched
vessels, black star: yellow structureless areas.
Figure 2a, b: The skin lesion resolved clinically and
dermoscopically.