Perforating Disseminated Necrobiosis Lipoidica Diabeticorum

Perforating necrobiosis lipoidica is a very rare clinical variant which consists of degeneration and transepidermal elimination of the collagen with few cases reported in the literature. In two-thirds of the patients it associates with diabetes, with no relation with the glucose control. We present a 42-year-old female patient with a 7-year history of diabetes on insulin therapy, referred to our clinic with a 3-year history of multiple asymptomatic firm plaques disseminated on the upper and lower extremities. The clinical and histological findings proved the diagnosis of perforating necrobiosis lipoidica. 1. Introduction Necrobiosis lipoidica diabeticorum is a rare idiopathic dermatological condition, commonly seen in women and frequently associates with diabetes. The perforating variant of disease in which necrotic collagen eliminates via transfollicular perforations is very seldom. We present a case of type II diabetes patient with disseminated perforating necrobiosis lipoidica (PNL). According to our knowledge this is one of very few cases published in the literature. 2. Case Report A 42-year-old Caucasian female patient suffering from long-term diabetes mellitus type II, controlled with rapid and retard acting insulin, was referred to our clinic. She complained of multiple asymptomatic firm plaques on the upper and lower extremities which enlarged peripherally and formed dark-brown centrally depressed plaques that appeared about 3 years ago. There was no history of trauma or operative interventions on the involved areas. One year later multiple reddish papules appeared on the upper extremities and slowly enlarged formatting indurated plaques. The clinical examination revealed infiltrated plaques disseminated on the extensor surfaces of the upper and lower extremities. The lesions on the lower extremity were presented by brown-yellow plaques with different sizes, irregular shape, sharp slightly elevated border, and atrophic center focally studded with comedo-like papules (Figures 1 and 2). Some of the lesions are surrounded with erythematous halo and were painful at pressure. Figure 1: Infiltrated circinate plaques, erythematous border, and comedo-like papules in the center on the lower extremities of a 42-year-old diabetic patient. Figure 2: Close view of an irregularly shaped brown-yellow plaque with comedo-like papules. Systemic examination showed no diabetic retinopathy or neuropathy; arterial hypertension was controlled with propranolol with only single measurement of RR 150/90？mm/Hg at admission. Laboratory investigations however revealed