ABSTRACT
A 57-year-old female was presented with an irrepressible case of Necrobiosis Lipoidica considering the possibility of a surgical skin graft. Instead, a pulsed dye laser treatment was used as an alternate treatment. Previous case studies have been found in the literature on the effect of pulsed dye laser on Necrobiosis Lipoidica. The use of a pulsed dye laser in this case resulted in rendering the lesions asymptomatic for pain and a reduction in volume. Prolonged control was exhibited. From this case, we conclude that pulsed dye laser therapy is effective when increasing the number of treatments of laser therapy, and can be used as a treatment for Necrobiosis Lipoidica.
Introduction
A rare skin condition known as Necrobiosis Lipoidica is often found in conjunction with poorly controlled diabetes. Necrobiosis Lipoidica is three times more likely to occur in women than men and is more commonly found in people who have poorly controlled diabetes, or a family history of diabetes (Citation1) with roughly 0.3% of the diabetic population is afflicted with this disease (Citation2). However, it is known to occur in the absence of diabetes as it is also associated with rheumatoid arthritis.
Necrobiosis Lipoidica has some unique key characteristics. Typically found in the pretibial areas, although also found elsewhere (Citation3), Necrobiosis Lipoidica is often branded by irregular violaceous skin patches with ovoid plaques accompanied with yellow decaying atrophic centers throughout the lesion (Citation4).The result of the discoloration and plaque is due to degeneration of collagen; this produces a granuloma, thickening of blood vessel walls, fat deposition, and ultimately leading to ulceration. Despite the unique look of this disease, a biopsy is needed to diagnose it (Citation5).
There are no known underlying causes of Necrobiosis Lipoidica. However, there have been some theories posed on the etiology of this rare skin disorder. Some of these theories include vascular supply to the skin (Citation6), immunological responses (Citation7,Citation8), and abnormalities in dermal collagen (Citation9).
Historically, treatment of Necrobiosis Lipoidica has been ineffective and not very uniform in effectiveness due to the irregularity, rarity, and unknown underlying causes of this skin disease. Few experimental trials have been done on effective methods of treatment (Citation4). Some common treatments that help treat Necrobiosis Lipoidica are corticosteroids, antithrombotic agents, and skin grafts in severe cases.
The pulsed dye laser is known to help with vascular blood flow reduction (Citation10), shows signs of eliciting immunological responses in cutaneous lesions (Citation11), and is also known to help with collagen remodeling (Citation12). Using the theorized causes and abilities of the pulsed dye laser, this method could aid in the treatment of Necrobiosis Lipoidica.
Two previous case studies have been found in the literature, which have shown moderate success when treating Necrobiosis Lipoidica with pulsed dye laser. The first case study used low fluences and achieved minimal therapeutic effect (Citation13). In the second case study, pulsed dye laser destruction was preformed once every 8 weeks, for a total of three treatments. This method of treatment showed slight reduction in the size of the lesions (Citation14).
By using the laser for an extended treatment period compared to the previous case studies, we theorized that the lesions would stop growing or eventually decrease in size and a greater control over the lesions will be exhibited.
Case presentation
In this particular case, a 57-year-old white obese female with poorly controlled diabetes was presented with progressively growing and changing painful lesions of the lower extremities. After evaluation from primary care and dermatology, further treatment was sought for possible skin grafting with our service.
The lesions began to appear in early 2013 and had been growing progressively. Two painful lesions are found on the right leg. The first lesion is a 60 by 70 mm affected area on the right lateral shin which is a scaly, raised red/yellow lesion elevated 6–10 mm. The second lesion is found on the dorsal right foot and is 30 by 30 mm. This lesion is pink, without much scale and raised 10 mm. Past medical history shows a 2013 biopsy was inconclusive. In 2014, dermatology attempted treatment with tramicosamine 0.1% ointment, along with Fluocinonide cream and Desoximetasone gel. There was no resolution. The lesions and symptoms became exacerbated. At this point, the patient was referred to our service for further care and possible skin grafting. A repeat biopsy was performed. While awaiting biopsy results, the clinical presentation at this time, despite negative previous biopsy in 2013, was thought suspicious of Necrobiosis Lipoidica. Aspirin, topical hydrocortisone therapy, and recommendation of strict control of diabetes were instituted. Results from the repeat biopsy confirmed the clinical suspicion that the lesions were in fact, Necrobiosis Lipoidica. With no success of topical treatment and no improvement, other options were discussed with patient. Pulsed dye laser was suggested as a possible noninvasive treatment, due to known poor results with surgical methods. The pulsed dye laser was used in hopes of preventing further spread of the lesion.
Methods and materials
The laser used is a Candela V BEAM perfecta pulsed dye laser wavelength of 595 nm
Setting 10 mm spot
Fluence of 5 J/cm2 at pulse duration of 3 ms with intermediate cryogen
Double-stacked pulses in two passes without development of purpura
At the beginning of treatment, the patient was treated once a month for 3 months in a row, performing pulsed dye laser destruction on the areas. The treatments stopped at 3 months and the patient returned for a reevaluation. Pain and symptomology of the lesions showed some reduction. The areas also had some reduction in their raised character. Another series of treatments was instituted. At this point, an additional three treatments were performed, each treatment occurring every 3 months.
Results
After the additional three treatments, the lesions maintained the discoloration but showed a reduction in the raised nature. The superior lesion had a reduction from 6−10 to 1–2 mm and the foot lesion showed a reduction from 10 to 1 mm.
There was a significant improvement of symptomology, pain, and discomfort. The patient reported them as predominantly asymptomatic. We thus considered this the end point of treatment with follow-up.
Furthermore, symptomatic control of the lesions was observed over 12 months in conjunction with no change in character.
Discussion
This use of the pulsed dye laser as a treatment for Necrobiosis Lipoidica confirms our original belief that extending the treatment period would lead to decreased lesion size, diminished pain, and discomfort associated with Necrobiosis Lipoidica. Ultimately, pulsed dye laser therapy resulted in control of the lesions. These conclusions fall in line with the previous studies applying the pulsed dye laser as a method of treatment. Our experience, in this case is that treatment should be extended beyond 3 months and three treatments. In our case, six treatments occurred over a period of 12 months. Although complete resolution did not occur, we found treatment extension for a prolonged time helped render the lesions asymptomatic for pain and discomfort with a significant reduction in the raised character of the lesions.
Since there is limited data, more studies should be done to elucidate the outcome of pulsed dye laser treatment on Necrobiosis Lipoidica. However, we conclude from this case study that a prolonged treatment schedule can lead to control of symptomatic Necrobiosis Lipoidica.
References
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