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Li Pomi F, Motolese A, Paganelli A, Vaccaro M, Motolese A, Borgia F. Shedding Light on Photodynamic Therapy in the Treatment of Necrobiosis Lipoidica: A Multicenter Real-Life Experience. Int J Mol Sci 2024; 25:3608. [PMID: 38612420 PMCID: PMC11011432 DOI: 10.3390/ijms25073608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Necrobiosis Lipoidica (NL) is a dermatological condition characterized by the development of granulomatous inflammation leading to the degeneration of collagen and subsequent formation of yellowish-brown telangiectatic plaques usually localized on the pretibial skin of middle-aged females. Due to its rarity and unclear etiopathogenesis, therapeutic options for NL are not well-standardized. Among them, photodynamic therapy (PDT) is an emerging tool, although its efficacy has primarily been evaluated in single case reports or small case series. This study reports the real-life experience of a cohort of NL patients treated with PDT at the Section of Dermatology of the University Hospital of Messina and Reggio-Emilia. From 2013 to 2023, 17 patients were enrolled -5 males (29%) and 12 females (71%) aged between 16 and 56 years (mean age: 42 ± 13 years), with a median duration of NL of 8 years. The overall complete clearance (>75% lesion reduction) was 29%, while the partial clearance (25-75% lesion reduction) was 59%, with 12% being non-responders. This study adds to the little amount of evidence present in the literature regarding the effectiveness of PDT in the treatment of NL. Variability in treatment responses among patients underscores the need for personalized protocols, optimizing photosensitizers, light sources, and dosimetry. The standardization of treatment protocols and consensus guidelines are essential to ensure reproducibility and comparability across studies.
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Affiliation(s)
- Federica Li Pomi
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, 90127 Palermo, Italy;
| | - Alfonso Motolese
- Dermatology Unit, Department of Surgery, Infermi Hospital, AUSL Romagna, 47923 Rimini, Italy;
| | - Alessia Paganelli
- Dermatology Unit, Santa Maria Nuova Hospital IRCCS, 42123 Reggio Emilia, Italy; (A.P.); (A.M.)
| | - Mario Vaccaro
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy;
| | - Alberico Motolese
- Dermatology Unit, Santa Maria Nuova Hospital IRCCS, 42123 Reggio Emilia, Italy; (A.P.); (A.M.)
| | - Francesco Borgia
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy;
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Panse K, Herrera M, Fung M, Brassard A, Moussa K. Successful treatment of necrobiosis lipoidica and associated retinal vasculitis with tumor necrosis factor (TNF)-alpha inhibitor. Am J Ophthalmol Case Rep 2023; 32:101908. [PMID: 37560554 PMCID: PMC10407115 DOI: 10.1016/j.ajoc.2023.101908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/06/2023] [Accepted: 07/20/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE To report the clinical and histopathologic features of necrobiosis lipoidica and associated retinal vasculitis and describe successful treatment of both skin and eye manifestations with adalimumab, a tumor necrosis factor (TNF)-alpha inhibitor. OBSERVATIONS A 35-year-old patient with bipolar disorder and ocular hypertension was referred for evaluation of bilateral retinal vasculitis. Fluorescein angiography revealed bilateral occlusive retinal vasculitis. Physical exam was notable for multiple annular and round erythematous hyperpigmented and atrophic patches and plaques on both lower extremities. Skin biopsy revealed a diagnosis of necrobiosis lipoidica, a rare granulomatous skin disease. Both the patient's retinal vasculitis and skin patches responded favorably to treatment with adalimumab, a TNF-alpha inhibitor. CONCLUSIONS AND IMPORTANCE This case highlights the importance of obtaining a complete history and physical exam in patients who present with ocular inflammation, as extraocular manifestations of disease may be present. It also demonstrates the effectiveness of a multidisciplinary approach to evaluation and management of these patients, as both skin and eye involvement were successfully treated with adalimumab, a TNF-alpha inhibitor.
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Affiliation(s)
- Ketaki Panse
- Department of Ophthalmology & Vision Science, University of California, Davis, Sacramento, CA, USA
| | - Manuela Herrera
- University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Maxwell Fung
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - Alain Brassard
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - Kareem Moussa
- Department of Ophthalmology & Vision Science, University of California, Davis, Sacramento, CA, USA
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Sandhu VK, Alavi A. The role of anti-tumour necrosis factor in wound healing: A case report of refractory ulcerated necrobiosis lipoidica treated with adalimumab and review of the literature. SAGE Open Med Case Rep 2019; 7:2050313X19881594. [PMID: 31666953 PMCID: PMC6801891 DOI: 10.1177/2050313x19881594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Necrobiosis lipoidica is a chronic granulomatous disease historically associated
with diabetes. Necrobiosis lipoidica commonly presents with erythematous papules
or plaques on the anterior lower extremities, which can be ulcerated in up to
30% of patients. The pathophysiology of necrobiosis lipoidica is unknown but
proposed to be predominantly linked to microangiopathy. No treatment option for
necrobiosis lipoidica has shown consistent efficacy. Previous case reports have
shown immune-modulating agents to be reasonable treatment options for ulcerative
necrobiosis lipoidica. However, evidence for the tumour necrosis factor-alpha
inhibitor, adalimumab, is limited and contradictory. We report a case of a
74-year-old type 2 diabetic female with a 2-year history of multiple ulcerated
necrobiosis lipoidica plaques resistant to topical and systemic therapy.
Treatment with adalimumab showed complete re-epithelization of all ulcers by
week 28. Adalimumab may be an effective treatment option for ulcerated
necrobiosis lipoidica that has failed traditional therapies. Further reports of
adalimumab treatment of necrobiosis lipoidica and other chronic inflammatory
wounds are needed.
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Affiliation(s)
| | - Afsaneh Alavi
- Department of Dermatology, University of Toronto, Toronto, ON, Canada.,York Dermatology Center, Richmond Hill, ON, Canada
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Peckruhn M, Tittelbach J, Elsner P. Update: Treatment of necrobiosis lipoidica. J Dtsch Dermatol Ges 2017; 15:151-157. [PMID: 28214312 DOI: 10.1111/ddg.13186] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 10/18/2016] [Indexed: 11/30/2022]
Abstract
Necrobiosis lipoidica (NL) is a rare granulomatous disease of hitherto unclear etiology frequently seen in patients with diabetes. Characterized by its potential for ulcerations, it often presents a serious burden for those affected. There are currently neither German nor European guidelines for the treatment of NL. At the same time, standard treatment with topical or intralesional corticosteroids does not always show satisfactory results. We therefore set out to evaluate whether the various treatment regimens published since 2000 have actually expanded the therapeutic armamentarium in a relevant manner. Included were all publications that described more than one patient being treated with any given therapeutic modality. Overall, we analyzed data for 16 different treatment regimens reported in 49 publications. The largest amount of data exists for topical PUVA therapy, photodynamic therapy (PDT), and systemic treatment with fumaric acid esters. Remarkably, our analysis showed that with an increase in the number of documented patients treated with a given therapeutic modality, the proportion of those achieving a complete or partial response actually decreased. This was interpreted as publication bias. Thus, no clear recommendation can be given for second-line therapy in case topical or intralesional corticosteroids fail.
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Affiliation(s)
| | - Jörg Tittelbach
- Department of Dermatology, University Hospital, Jena, Germany
| | - Peter Elsner
- Department of Dermatology, University Hospital, Jena, Germany
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Peckruhn M, Tittelbach J, Elsner P. Update: Therapie der Necrobiosis lipoidica. J Dtsch Dermatol Ges 2017; 15:151-158. [PMID: 28214306 DOI: 10.1111/ddg.13186_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 10/18/2016] [Indexed: 11/28/2022]
Abstract
Die Necrobiosis lipoidica ist eine seltene granulomatöse Erkrankung von bisher unzureichend geklärter Ätiologie. Häufig stellt die bei Diabetikern gehäuft zu beobachtende und zur Ulzeration neigende Dermatose eine starke Belastung für die Patienten dar. Bezüglich der Therapie existieren aktuell keine deutschen oder europäischen Leitlinien. Gleichzeitig lässt sich unter der aktuellen Standardtherapie, der lokalen oder intraläsionalen Anwendung von Glukokortikoiden, nicht immer ein zufriedenstellendes Ansprechen beobachten. Daher wurde untersucht, ob seit dem Jahr 2000 publizierte Therapiemodalitäten das Therapiespektrum relevant und erfolgversprechend erweitern. Es erfolgte eine Betrachtung aller Arbeiten im oben genannten Zeitraum, bei denen mehr als ein Einzelfallbericht je Therapiemodalität publiziert wurde. Insgesamt wurden in einem systematischen Review die Daten von 16 verschiedenen, seit 2000 publizierten Therapieverfahren in 49 Publikationen analysiert. Im Ergebnis zeigte sich, dass die meisten Erfahrungen bezüglich der topischen PUVA-Therapie, der photodynamischen Therapie (PDT) und der systemischen Therapie mit Fumarsäureestern vorliegen. Allerdings ist auffällig, dass mit steigender Zahl der pro Behandlungsmodalität behandelten Patienten der Anteil der Patienten, bei denen eine Abheilung bzw. eine teilweise Abheilung berichtet wurde, sinkt. Wir interpretieren diese Beobachtung als Publikationsbias. Daher kann für keines der besprochenen Verfahren eine klare Empfehlung als Therapie der zweiten Wahl nach Versagen der lokalen bzw. intraläsionalen Steroidtherapie gegeben werden.
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Affiliation(s)
| | | | - Peter Elsner
- Klinik für Hautkrankheiten, Universitätsklinikum Jena
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Basoulis D, Fragiadaki K, Tentolouris N, Sfikakis PP, Kokkinos A. Anti-TNFα treatment for recalcitrant ulcerative necrobiosis lipoidica diabeticorum: A case report and review of the literature. Metabolism 2016; 65:569-73. [PMID: 26975548 DOI: 10.1016/j.metabol.2015.12.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/29/2015] [Accepted: 12/30/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Necrobiosis lipoidica diabeticorum (NLD) is a rare degenerative connective tissue disorder associated with diabetes mellitus, which usually presents with red papules or plaques with raised edges and occasional ulceration. Ulcerating NLD is notoriously difficult to treat. We present a young patient with ulcerative NLD who was successfully treated with the anti-TNFα agent infliximab. Case presentation is followed by a review of therapeutic TNFα blockade in NLD. CASE PRESENTATION A 17-year old woman with type 1 diabetes since the age of 8, presented with a long-standing and extensively ulcerated and infected NLD lesion on her left shin. After achieving better glycemic control and treating her for infection of the wound, several NLD treatments failed to help, including corticosteroids and hyperbaric oxygen. She was treated successfully with 4 monthly sessions of 5mg/kg body weight intravenous infliximab, achieving complete resolution of ulceration. DISCUSSION A multitude of available treatments have been suggested for NLD over the past decades, based on two axes, one through wound healing and the other through immunosuppression. Anti-TNFα agents are relatively new drugs that brought a revolution in chronic inflammatory diseases and have been on the rise as novel potential treatments for NLD. Three out of the five available anti-TNFα agents have been safely tested so far, both topically and systematically, with mostly favorable results. CONCLUSION Intravenous infliximab was successful in the treatment of recalcitrant ulcerating NLD in our patient. Taken together with an increasing number of similar reports revealing a pathogenetic role of TNFα in NLD, we suggest that anti-TNFα agents are promising drugs in the management of this condition.
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Affiliation(s)
- Dimitrios Basoulis
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
| | - Kalliopi Fragiadaki
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
| | - Nicholas Tentolouris
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
| | - Petros P Sfikakis
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
| | - Alexander Kokkinos
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
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Abstract
The advent of biologics in dermatologic treatment armentarium has added refreshing dimensions, for it is a major breakthrough. Several agents are now available for use. It is therefore imperative to succinctly comprehend their pharmacokinetics for their apt use. A concerted endeavor has been made to delve on this subject. The major groups of biologics have been covered and include: Drugs acting against TNF-α, Alefacept, Ustekinumab, Rituximab, IVIG and Omalizumab. The relevant pharmacokinetic characteristics have been detailed. Their respective label (approved) and off-label (unapproved) indications have been defined, highlighting their dosage protocol, availability and mode of administration. The evidence level of each indication has also been discussed to apprise the clinician of their current and prospective uses. Individual anti-TNF drugs are not identical in their actions and often one is superior to the other in a particular disease. Hence, the section on anti-TNF agents mentions the literature on each drug separately, and not as a group. The limitations for their use have also been clearly brought out.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
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Franklin C, Stoffels-Weindorf M, Hillen U, Dissemond J. Ulcerated necrobiosis lipoidica as a rare cause for chronic leg ulcers: case report series of ten patients. Int Wound J 2013; 12:548-54. [PMID: 24119190 DOI: 10.1111/iwj.12159] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/20/2013] [Indexed: 11/27/2022] Open
Abstract
Necrobiosis lipoidica is a rare granulomatous disorder of the skin. In up to 30% of the affected patients it can lead to ulcerations, which can impair the quality of life and are also very difficult to treat. Its pathogenesis is not fully understood. Only few studies focussing on necrobiosis lipoidica can be found, but none of them focus on ulcerated necrobiosis lipoidica. Therefore, we collected demographic data and comorbidities and assessed treatment options for patients with ulcerated necrobiosis lipoidica. Data of patients who were treated in the wound care centre of the University Hospital of Essen for ulcerated necrobiosis lipoidica over the past 10 years were retrospectively analysed. Hence, data of altogether ten patients (nine women and one man) with ulcerated necrobiosis lipoidica were collected. Of these, 70% of the patients had diabetes mellitus of which 30% had type I diabetes and 40% had type II diabetes; 60% of the patients suffered from arterial hypertension, obesity and hypercholesterolaemia; 40% of the patients suffered from psychiatric disorders such as depression and borderline disorder. Our clinical data demonstrate an association of ulcerated necrobiosis lipoidica and aspects of metabolic syndrome. This leads to a conclusion that ulcerating necrobiosis lipoidica can be seen as part of a generalised inflammatory reaction similar to the inflammatory reaction already known in the pathophysiology of rheumatoid diseases or psoriasis. In patients with clinical atypical painful ulcerations, necrobiosis lipoidica should be considered as a possible differential diagnosis. Therapists should be aware of associated aspects in patients with ulcerated necrobiosis lipoidica who besides diabetes often suffer from other aspects of a metabolic syndrome with increased cardiovascular risk factors. Therefore, these related comorbidities should also be diagnosed and treated.
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Affiliation(s)
- Cindy Franklin
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Maren Stoffels-Weindorf
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Uwe Hillen
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Joachim Dissemond
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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