Case Number : Case 785 - 20th June Posted By: Guest

Although I can't see large necrobiotic foci there is a suggestion of a layered pattern with horizontal bands of granulomatous inflammatory infiltrates alternating with hypocellular sclerotic bands. The inflammatory cells are represented by lymphocytes, histiocytes and plasma cells. I think this is an early lesion of necrobiosis lipoidica.

Necrobiosis lipoidica

Although seeing plasma cells always alert me to non-visble amyloidosis in the skin, I do agree with [color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4][right]Romualdo and [/right][/size][/font][/color][color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4][right]Marcela for [/right][/size][/font][/color][color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4] necrobiosis lipoidica.[/size][/font][/color]

I observe a foci of necrobiosis on mid lett photo at the rigth bottom egde, fibrosis and lots of plasma cells, but everything became easier after Romualdo´s sugestion.

Pictures show three features that make me favor early necrobiosis lipoidica over interstitial granuloma annulare: infiltrate is more concentrated on lower part of the reticular dermis, frequent plasma cells, and horizontally oriented tiers of histiocytes. Furthermore, shin is the most typical site for necrobiosis lipoidica.
I couldn’t check unequivocally, based only in the available pictures, the most reliable feature to distinguish necrobiosis lipoidica and granuloma annulare, to wit, the intervening dermis, which is altered in the former and normal in the latter.

KS

Necrobiosis lipoidical

Favor NLD also

I can see this being NLD. Anyone think it could me morphea? That also crossed my mind given the plasma cells and sclerosis.

I would favor an old lesion NLD, given the horizontal tiering of the collagen bundles and inflammatory infiltrate, overall dermal thickening, mixed lymphoplasmacytic inflammatory infiltrate, and clinical context of female shin.

Having said that, there is absence of classic necrobiosis, and limited scope of the images.
I will therefore keep the following in the differential:

1. Morphea[list]
[*]Obliteration of fat around the eccrine coils (bound-down adnexa) best seen in the first (top left) photo.
[*]Mixed lyphoplasmacytic cells in inflammatory/early stage.
[*]Thick dermis (no subcutis).
[/list]
2. Dermatofibroma :[list]
[*]Frequently have an associated lymphocytic or lymphoplasmacytic inflammatory reaction (predominantly peripheral).
[*]Mulitnucleated and single cells that wrap around collagen bundles.
[*]Thickened collagen bundles.
[*]Epidermal hyperplasia and/or hyperpigmentation.
[/list]

Well done, it is necrobiosis lipoidica diabeticorum.

Well, in my opinion morphea, granuloma anulare and necrobiosis lipoidica were possible diagnosis. Thank you very much for share this case whith us.