Healing of chronic leg ulcers in diabetic necrobiosis lipoidica with local granulocyte-macrophage colony stimulating factor treatment

Literaturrecherche zur Therapie der Necrobiosis lipoidica in der Kindheit

Die Necrobiosis lipoidica (NL) ist eine seltene granulomatöse Erkrankung mit scharf begrenzten, teleangiektatischen, braun‐roten Plaques mit atroph‐gelblichen Zentren, die zu Ulzerationen neigen und hauptsächlich an den Schienbeinen auftreten. Bei Kindern ist NL sehr selten, jedoch sind die Therapieresistenz, das problematische kosmetische Erscheinungsbild, die schmerzhaften Ulzerationen und die mögliche Entwicklung von Plattenepithelkarzinomen besonders herausfordernd für diese Altersgruppe. Unsere Literaturrecherche inkludiert 29 Berichte über NL bei Patienten unter 18 Jahren, die seit 1990 auf PubMed, EMBASE und Medline publiziert wurden. Das mittlere Alter war 14,3 Jahre mit weiblicher Prädominanz von 2 : 1 und hoher Prävalenz von Diabetes mellitus (80%). Aus den Daten geht hervor, dass hochpotente topische Steroide bis zu zweimal täglich Behandlung erster Wahl sind. Therapierefraktäre Fälle können auf Tacrolimus umgestellt werden. Ulzerationen profitieren von phasenadaptierter Wundversorgung und antientzündlichen medizinischen Verbänden wie mit medizinischem Honig. Das Hinzufügen einer hyperbaren Sauerstoffbehandlung zur lokalen oder systemischen Therapie kann bei schwer behandelbaren ulzerierten Läsionen in Betracht gezogen werden. Therapieresistente Fälle können umgestellt werden auf topische Photochemotherapie oder systemische Behandlung mit TNF‐alpha‐Inhibitoren, systemischen Steroiden (bevorzugt bei Patienten ohne Diabetes), Pentoxifyllin oder Hydroxychloroquin. Necrobiosis lipoidica in der Kindheit ist mit über 40% fehlgeschlagenen Therapieversuchen schwer zu behandeln, weshalb weitere Forschung über Patientenregister empfohlen wird.

Necrobiosis lipoidica in childhood: a review of literature with emphasis on therapy

Necrobiosis lipoidica (NL) is a rare chronic granulomatous disease that manifests as sharply demarcated, telangiectatic, brownish-red plaques with atrophic yellowish centers prone to ulceration and occurs predominantly on the shins. In children, NL is extremely rare, but resistance to therapy, troublesome cosmetic appearance, painful ulcerations, and possible development of squamous cell carcinoma in long-persisting lesions are challenges during treatment. Our review includes 29 reports of NL in patients aged <18 years published from 1990 on PubMed, EMBASE, and Medline. The mean age of patients was 14.3 years, with a female predominance of 2 : 1 and a high prevalence of diabetes mellitus (80%). Data showed that potent topical steroids up to twice daily is the first-line treatment. For refractory cases, therapy can be switched to tacrolimus. Ulcerations benefit from phase-adapted wound care and anti-inflammatory medical dressings such as medical honey. Adding hyperbaric oxygenation to local or systemic therapy in difficult-to-treat ulcerated lesions can be considered. Refractory cases may be switched to topical photochemotherapy or systemic treatment with TNF-α inhibitors, systemic steroids (preferably in non-diabetic patients), pentoxifylline, or hydroxychloroquine. Necrobiosis lipoidica in childhood is difficult to treat, with a treatment failure rate of 40%. Therefore, further research through patient registries is recommended.

A new atypical form of lipoid necrobiosis not associated with diabetes mellitus

A 55-year-old woman has lipoid necrobiosis of both legs, complicated by ulceration. The first manifestations of the disease appeared after an injury in the region of the left shin, an abrasion appeared, which later transformed into a glossy spot that slowly increased in size. She first sought medical help in 2017 and was clinically diagnosed with necrobiosis lipoidica. The prescribed treatment did not lead to an improvement in the patients condition. In 2021, after vaccination against COVID-19, the patient notes a sharp deterioration in the process. No convincing data for diabetes mellitus received. She has a history of multinodular non-toxic goiter, for which in 1995 a complete resection of the left lobe of the thyroid gland was performed and in 2003 a partial resection of the right lobe of the thyroid gland. The patient has been receiving L-thyroxine replacement therapy since 2003. A biopsy of the affected skin was taken. The final diagnosis was established according to the pathological and anatomical study of the biopsy. As a result of the treatment, the patient was discharged from the clinic with improvement.

Benefits of Hesperidin for Cutaneous Functions

Hesperidin is a bioflavonoid, with high concentration in citrus fruits. In addition to its well-known benefits for cardiovascular function, type II diabetes, and anti-inflammation, recent studies have demonstrated multiple benefits of hesperidin for cutaneous functions, including wound healing, UV protection, anti-inflammation, antimicrobial, antiskin cancer, and skin lightening. In addition, hesperidin enhances epidermal permeability barrier homeostasis in both normal young and aged skin. The mechanisms by which hesperidin benefits cutaneous functions are attributable to its antioxidant properties, inhibition of MAPK-dependent signaling pathways, and stimulation of epidermal proliferation, differentiation, and lipid production. Because of its low cost, wide availability, and superior safety, hesperidin could prove useful for the management of a variety of cutaneous conditions.

The treatment of necrobiosis lipoidica

Necrobiosis lipoidica is an inflammatory disorder, associated with diabetes mellitus, for which the underlying pathological mechanism is unknown and for which there is no rational therapy. However, benefit has been reported from such different treatment regimens as drugs acting on the haemostatic mechanisms, corticosteroid therapy (topical, intralesional and systemic), enhancers of wound healing, surgery and immunomodulating therapies (including photochemotherapy). This is a review of these treatment options.

Ulcerated Necrobiosis Lipoidica: A Combined Treatment Approach with Dermatosurgery and PUVA

Ulcerated necrobiosis lipoidica is one of the differential diagnoses in leg ulcers. The diagnosis is confirmed by histopathology. The authors report on a 68-year-old female patient with a history of chronic venous insufficiency who developed a chronic leg ulcer that did not respond to good ulcer care and compression bandaging. Skin biopsies revealed necrobiosis lipoidica. The patient was recently discovered to have diabetes mellitus that was treated orally by ascarose. Phlebosurgery and mesh grafting were performed, and the patient was given pentoxyfiline, dapsone, and clofazimine, but none of these treatments was successful. Therefore, topical PUVA therapy was introduced that resulted in partial remission and stabilizing of the residual pathology. Based on these experiences, the use of surgical methods alone is questionable.

Necrobiosis Lipoidica

Necrobiosis lipoidica is a granulomatous condition presenting as indolent atrophic plaques, often on the lower extremities. There is a multitude of case reports suggesting possible associations and documenting different therapeutic alternatives with varied success. Important complications include ulceration and the development of squamous cell carcinoma. The disease course is often indolent and recurrent despite treatment. This article reviews the etiopathogenesis, clinical presentations, and evidence for treatment alternatives of this condition.

Treatment Modalities of Necrobiosis Lipoidica: A Concise Systematic Review

Necrobiosis lipoidica (NL) is a rare inflammatory granulomatous skin disorder closely associated with diabetes mellitus. The aim of this paper is to review and discuss all the treatment modalities proposed and tested for this disease. A systematic review of the existing literature was conducted to investigate all the available data and summarize all the clinical trials, case reports and original articles on NL. Two major databases (PubMed and Google Scholar) were used. We have examined about 70 articles. Numerous treatment modalities have been currently investigated to compare recalcitrant NL. Being rare, most of the studies regarding this disease are case reports or small-scale clinical trials. We have found that, in spite of plentiful investigations carried out during the years, there is no treatment modality that has proved to be utterly satisfactory in treating NL.

Selective case study describing the use of Apligraf on necrobiosis lipoidica associated with diabetes

Necrobiosis lipoidica is a rare skin disease characterised by large, well-demarcated, symmetrical plaques with overlying telangiectasias and atrophic, fibrotic features. The disease is associated with diabetes mellitus (1 in 300 cases), but can also be linked to other diseases such as rheumatoid arthritis. Women are three times more likely to develop necrobiosis lipoidica compared to men. Ulcerations are the most serious type of complications in necrobiosis lipoidica, and they occur most frequently on the legs of patients. However, the aetiology of necrobiosis lipoidica still remains unclear. Although many studies have been conducted in order to determine necrobiosis lipoidica's pathophysiology, a clear and definite path to disease has not been recorded. In this case study, a patient with necrobiosis lipoidica that had been refractory to conventional therapy received treatment with Apligraf® bioengineered wound dressings. Apligraf was shown to be effective in managing the patient's multiple hard-to-heal wounds. It was more successful than previous therapies in achieving granulation tissue formation and wound volume reduction, in addition to being a more rapid form of treatment.

Treatment of Ulcerative Necrobiosis Lipoidica with Topical Calcineurin Inhibitor: Case Report and Literature Review

Background:

Ulcerative necrobiosis lipoidica (UNL) is an uncommon disease, which is frequently recalcitrant to available therapies. It is characterized by well-defined, ulcerated plaques with indurated borders and atrophic centers. Multiple therapeutic options have been described, with variable success rates.

Objective:

To report the efficacy of using topical tacrolimus in treating UNL.

Method:

Topical tacrolimus was used in the treatment of two patients with UNL.

Result:

Topical tacrolimus is effective in treating UNL.

Conclusion:

Topical tacrolimus is a reasonably effective choice in treating UNL.

Contexte:

La nécrobiose lipoïdique ulcérée (NLU) est une maladie rare, qui est souvent réfractaire au traitement. Elle se caractérise par des placards ulcérés et bien définis, des bords indurés et des centres atrophiques. Différentes formes de traitement ont été utilisées et se sont soldées par des taux variables de réussite.

Objectif:

L'étude visait à faire état de l'efficacité du tacrolimus topique dans le traitement de la NLU.

Méthode:

Nous avons fait usage de tacrolimus topique dans le traitement de la NLU chez deux patients.

Résultat:

Le tacrolimus topique s'est montré efficace dans le traitement de la NLU.

Conclusion:

Le tacrolimus topique est un moyen relativement efficace de traitement de la NLU.

Periorbital necrobiosis lipoidica diabeticorum: case report

Necrobiosis lipoidica diabeticorum (NLD) is a relatively common manifestation of diabetes mellitus that is thought to be related to immune-complex vasculitis. The legs are the most common site for NLD, but other locations, such as the forearms or hands, have been reported. We describe a case of periorbital NLD that was diagnosed on the basis of histopathology.

Local injections of granulocyte-macrophage colony-stimulating factor (Gm-CSF) for the treatment of radiation-induced mucosa ulcers

We report two cases illustrating how Gm-CSF can facilitate rapid and persistent healing of ulcers associated with contact radiation therapy. This simple and safe method should be proposed for the treatment of chronic ulcers that develop in a formerly radiated zone.

Necrobiosis lipoidica diabeticorum treated with the pulsed dye laser

BACKGROUND AND OBJECTIVE

Different treatment modalities have been advocated for necrobiosis lipoidica diabeticorum but clinical response is unpredictable. The purpose of this study was to evaluate the usefulness of pulsed dye laser (Candela SPTL, Irvine, MA, USA) in the treatment of an area of necrobiosis lipoidica of 4 cm in diameter on the anterior aspect of the leg in a non-diabetic patient.

MATERIALS AND METHODS

A spot test was made at 6.0, 6.5 and 7.0 J/cm(2) energy fluences and the best energy fluence was selected after a 2-month postoperative evaluation. The patient received three treatment sessions with a fluence of 6.5 J/cm(2), 585-nm wavelength, 5-mm spot size, and 450 micro(s) pulse duration at 8-week intervals. The patient was given routine skin care advice with emollient cream and sunscreen (SPF 15) until the following session.

RESULTS

Overall cosmetic improvement was achieved, with a decrease of erythema and telangiectasis, and stabilization in terms of progression (size) in the left half of the lesion, with no modification of atrophy or pigmentary changes. The right upper quadrant of the lesion showed an erythematous peripheral halo with minimal reduction in the erythema and telangiectasia, and discrete size increase.

CONCLUSION

Pulsed dye laser may be a useful treatment for improving the telangiectasia and erythematous component of necrobiosis lipoidica.

Squamous cell carcinoma developing in necrobiosis lipoidica

We describe a case of squamous cell carcinoma arising in long-standing necrobiosis lipoidica in a type 1 female diabetic patient. The tumour and the skin lesion were successfully excised and repaired with full thickness skin graft. The development of squamous cell carcinoma in association with this skin disorder is rare (only four cases reported in literature since 1966), but should be considered in chronic, non-healing and recalcitrant ulcers developing within areas of necrobiosis lipoidica.

Management of leg ulcers

Leg ulcer is a leading cause of morbidity among older subjects, especially women in the Western world. About 400 years BC, Hippocrates wrote, "In case of an ulcer, it is not expedient to stand, especially if the ulcer be situated on the leg". Hippocrates himself had a leg ulcer. The best treatment of any leg ulcer depends upon the accurate diagnosis and the underlying aetiology. The majority of leg ulcers are due to venous disease and/or arterial disease, but the treatment of the underlying cause is far more important than the choice of dressing. The aetiology, pathogenesis, treatment, and the future trends in the management of the leg ulcers are discussed in this review.