Remission of Ulcerated Necrobiosis Lipoidica Diabeticorum after Bariatric Surgery

A 32-year-old woman with type 2 diabetes mellitus suffering from morbid obesity with BMI 45,14？kg/m2 was operated on. Not only the type 2DM but also one of its complication known as necrobiosis lipoidica diabeticorum remitted postoperatively. Obesity should no longer be regarded simply as a cosmetic problem affecting certain individuals but an epidemic that threatens global well-being. It causes or exacerbates many health problems, and in particular, it is associated with the type 2 diabetes. Necrobiosis lipoidica is a granulomatous skin disease of unknown etiology, associated mainly with diabetes mellitus. We presented in this paper a morbid obese case of necrobiosis lipoidica diabeticorum with dramatic good response to bariatric surgery. 1. Introduction Obesity should no longer be regarded simply as a cosmetic problem affecting certain individuals but an epidemic that threatens global well-being. It causes or exacerbates many health problems, and in particular, it is associated with the T2DM. Necrobiosis lipoidica is a granulomatous skin disease of unknown etiology, associated with diabetes mellitus which responds with limited success to many treatment options. We report in this paper a case of NLD treated successfully with bariatric/metabolic surgery. 2. Case Report A 32-year-old woman was operated on for morbid obesity with BMI 45,14？kg/m2 in April 2011. She had diabetes mellitus for 12 years. She has been under 1？U/kg/day insulin therapy since 2002 (2/3 (96？U) insulin aspart and 1/3 (30？U) insulin glargine). She had bilateral, almost circumferential, persistent plaques with depressed central areas and elevated peripheral rings over legs. The lesions are ulcerated and oozing with moderate to severe pain which partially respond to pain killers (Figure 1). The punch biopsies were performed, and the histopathologic examination of the lesions revealed the loss of epidermis rete associated with degenerative collagenous plaques in the dermis with peripheral histiocytic palisades (Figure 2(a)). Also associated subcutaneous multiple granuloma with plasma cells, lymphocytes and multinuclear giant cells (Figure 2(b)). The pathologic diagnosis was necrobiosis lipoidica. She was prescribed steroid for topical use and was treated with psoralen plus ultraviolet A photochemotherapy and also with different kind of skin dressings which were unsuccessful. She had undergone laparoscopic minigastric bypass. From the first postoperative day, she left the insulin and pain killers and after a month the lesions on the left leg subsided. She experienced the same regression