Necrobiosis Lipoidica Diabeticorum
Saturday, January 01, 2011
Lesions of necrobiosis lipoidica diabeticorum (NLD) are usually,
but not always, associated with juvenile-onset diabetes. Tending to
occur singly or in crops on the anterior lower legs, they can
appear anywhere on the body. Lesions on the leg exhibit more of a
tendency to ulcerate than lesions elsewhere.
- For nonulcerated, symptomatic lesions (asymptomatic lesions
need not be treated), intralesional triamcinolone acetonide 3-5
mg/ml. Small amounts of this solution are injected intradermally
into plaques via a 30-guage needle. Injections are repeated every
- Application of superpotent topical steroids with occlusion for
several weeks can be effective.
- Administration of pentoxiphylline 400-800 mg three times plus
ASA 81 mg daily.
- For persistent erythema and telangiectasia, not resolving with
the above therapy, pulse dye laser can be utilized for cosmetic
- Topical tacrolimus ointment 0.1% may be used for refractory
- Topical or systemic PUVA may improve NLD, and can even be used
in cases with ulceration, with reduction in pain after several
- In severe refractory cases requiring systemic treatment,
consider the following options:
a. Cyclosporine 2.5-5 mg/kg per day for several months
b. Mycophenolate mofetil 2-3 g/day
c. Infliximab 5 mg/kg per treatment for a total of 3 treatments at
0, 2, and 6 weeks.
- NLD has a tendency to ulcerate. These ulcerations may be
infected by bacteria, so nonhealing lesions should be cultured, and
appropriate topical and oral antibiotics should be considered if
the methods outlined below are ineffective. At times the ulcerated
lesions will be very painful. The techniques used to heal chronic
ulcers can be applied to the ulcerated lesions of NLD, including
a. Application of semipermeable dressings
b. Becaplermin applied once daily to the ulceration for 12 hours,
or once weekly under occlusive, semipermeable dressing, as for
venous insufficiency ulcers.
c. Topical or intralesional granulocyte-macrophage
d. Dermagraft or other skin substitute equivalent applied at
regular intervals. Multiple applications may be required. This is
frequently very effective in reducing/eliminating the pain as well
as stimulating ulcer healing.
- Lesions of NLD can be very resistant to the above management,
and may not respond. Moreover, new lesions may continue to
- There is no relationship between severity of NLD and diabetic