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A 48-yr old diabetic man, BMI 35, C/O bilat hyperparaesthesiae for about 1/12. There's Hx of poor glucose control-A1C 9.3% and Serum glucose of 10.7mmol/l. Has mild varicosities with no stasis dermatitis. The patient also has dyslipidemia and smokes 20 cig/day for approx 30 years. He's on a combined insulin and oral therapy.

Blood tests confirmed microcytosis, hypochromia and erythrocytosis. AST and URCA are increased. Deep tendon reflexes were absent and other systems' exams were unremarkable.

On L/F dorsal aspect, patient presented with brownish, macular lesions with multiple satellites (SEE PICTURES BELOW). The patient says the lesions began +/-3yrs ago as bright red macules. The mother lesion is increasing in size, but there is no Hx of pruritis. Biopsy and dermatologist's opinion have been sought.

Is there any reason to worry or this is just hemosiderin deposits from varicosities??????? Richard M.:bang:

 

Re: What is your Possible Diagnosis?

The three years throws me, but... contact dermatitis?

 

Re: What is your Possible Diagnosis?

Have you ruled out necrobiosis lipoidica diabeticorum?

Its true that it usually manifests on the shins but can appear anywhere. Tx choices can include cortisone (either through applying cream or by injection to the affected area) Or ulltraviolet light has also been shown to be of use in the event of a flare up.

Unfortunately the disease is typically chronic.

Cheers,
Bel

 

Re: What is your Possible Diagnosis?

Could be Necrobiosis lipoidica diabeticorum

Necrobiosis lipoidica (NL) is an inflammatory skin disorder characterized by irregularly shaped, callous lesions with reddish-brown pigmentation and central atrophy.

The pathology is collagen degeneration with granulomatous response, associated with thickened blood vessels and fat deposition. Underlying cause is unknown: aetiology has suggested to be an antibody-mediated vasculitis with secondary collagen degeneration or diabetic microangiopathy.

Regards

Gill

 

Re: What is your Possible Diagnosis?

Necrobiosis lipoidica diabeticorum is a good bet. I've read that despite the name it's not necessarily associated with diabetes, although thinking about it most patients i've seen with have been diabetic. Anybody got thoughts on typical patient demographic?

Ian

 

Re: What is your Possible Diagnosis?

Ian

This is taken from www.patient.co.uk

Epidemiology

NL is a rare skin condition. Whilst there is a high prevalence of diabetes mellitus in patients with NL (50% NL occurs in diabetics), the reported prevalence of NL in diabetic patients is less than 1%. It most commonly presents in the 30s but can present at any age including infancy. It tends to appear earlier in diabetics than in others: in one study, approximately 2% young diabetics (aged up to 22 years)had a NL lesion compared to none of the control subjects. It is 3 times as common in women as in men. Non-diabetic familial clustering of NL does occur but extremely rarely.

Smoking is more prevalent in diabetic patients with NL than without, as are diabetic complications (retinopathy and nephropathy) although the presence of NL does not correlate with diabetic control.


Gill

 

Re: What is your Possible Diagnosis?

Thank you colleagues for quick responses, much appreciated. Am also awaiting biopsy results.
Richard M.

 

Update on necrobiosis lipoidica: A review of etiology, diagnosis, and treatment options
Sophia D. Reid, Barry Ladizinski, Kachiu Lee, Akerke Baibergenova, Afsaneh Alavi
Journal of the American Academy of Dermatology; Article in Press

 

My boss is currently offline in the out back; I will endeavour to get this to her when she is back, Rob. PS, Richard, good to hear from you

 

Re: What is your Possible Diagnosis?

Richard,

I know this was over four years ago, but can you remember the biopsy results?

Bel

 

Effectiveness of platelet-rich plasma in healing necrobiosis lipoidica diabeticorum ulcers
A. Motolese, F. Vignati, A. Antelmi and V. Saturni
Clinical and Experimental Dermatology; Early View