Treatment of Refractory Ulcerative Necrobiosis Lipoidica Diabeticorum With Infliximab

Abstract

Background: Necrobiosis lipoidica diabeticorum (NLD) is a rare, granulomatous inflammatory skin disease of unknown origin, sometimes associated with diabetes mellitus. Skin lesions usually develop on the lower extremities and can progress toward ulceration and scarring. Many treatments have been proposed, but few have demonstrated consistent efficacy, and no standard regimens have emerged to date. Observations: An 84-year-old woman with type 1 diabetes mellitus presented with a 3-year history of chronic right-lower-extremity erythematous papules and plaques that had developed into confluent ulcers with prominent granulation tissue and an orange-yellow hue. The results of a biopsy of the lesion was consistent with a diagnosis of NLD. The wound did not respond to 4 months of intensive local wound care. After the first intravenous infusion of infliximab (5 mg/kg), there was rapid reduction in wound size, pain, and drainage. There was complete wound healing with excellent cosmesis at 6 weeks (total of 3 infusions). Conclusions: Infliximab should be considered in the treatment of refractory, ulcerative NLD. Its anti-tumor necrosis factor activity may underlie its efficacy in targeting this granulomatous process, and further investigation should be undertaken to confirm these results.

Cyanidin-3-O-β-glucoside inhibits LPS-induced expression of inflammatory mediators through decreasing IκBα phosphorylation in THP-1 cells

“…Inhibition of such inflammatory agents will reduce or inhibit disease progression. Therapy with anti-TNFa drugs or antibodies was shown to improve insulin sensitivity and decrease cardiovascular risk index [14][15][16]. A substantial number of studies show that there are a number of signaling pathways involved in the regulation of inflammation, with nuclear factor-kappa B (NF-jB) being a key component.…”

Does inflammation play a role in development of necrobiosis lipoidica?

“…The authors of these publications suggest that it may result from an important role of TNF-α in generation of granulomas and pathogenesis of NL [13][14][15][16].…”

“…Some authors also suggest immunological disturbances leading to deposits of immunoglobulins in skin vessels and disturbances in platelet aggregation [8][9][10][11][12]. Recent literature data show that tumor necrosis factor α (TNF-α) inhibitors such as adalimumab, infliximab or etanercept are beneficial in treatment of recalcitrant cases of necrobiosis lipoidica, which probably results from the fact that TNF-α plays an important role in development of inflammation and granulomas in the course of NL [13][14][15][16].…”

Necrobiosis Lipoidica Therapy with Biologicals: An Ulcerated Case Responding to Etanercept and a Review of the Literature

“…A PubMed search about the treatment of NL with biological agents returned 6 previously reported cases in the English-language literature [19,20,21,22,23,24]. Clinical characteristics are summarized in table 1.…”

“…Improvement of NL was seen after the first month of treatment, and the lesion continued to resolve over the next 8 months. In 2009, Hu et al [23] reported complete healing in an 84-year-old woman with chronic ulcerated NL of her right lower extremity after 3 infusions of infliximab (5 mg/kg at weeks 0, 2 and 6). In 2009, Zhang et al [24] published the case of a 29-year-old woman with NL affecting her lower extremities and trunk successfully treated using 50 mg subcutaneous etanercept injections twice weekly for 3 months, then weekly after that.…”