Necrobiosis lipoidica diabeticorum

Necrobiosis lipoidica diabeticorum (NLD) consists of oval plaques, usually on
the lower legs. It may start as small red spots or raised areas, which
develop a shiny, porcelain-like appearance. The plaques often turn a light
color due to extracellular fat (the "lipoidica"). They are often itchy or
painful. Typically the spots turn a brownish color, which fades slowly but
is permanent.

NLD is not related to any other complication of diabetes. In particular, NLD
does not presage eye, kidney or vascular problems.

NLD is much more common in diabetics, who account for perhaps 2/3 of all
cases. Many of the remainder develop diabetes, and NLD should be considered a
warning sign of diabetes. Reports vary widely on exactly who is most at risk.
About 1% of diabetics have some degree of NLD ... plus or minus 1%, depending
on which report you read. Some reports say NLD occurs more often in young
women, but some textbooks disagree.

The real dangers seem to be ulceration, infection, and the stress from the
appearance. Ulceration sometimes occurs spontaneously, and often as a result
of trauma.

Ulceration is often a result of scratching or trauma, and the ulceration from
scratching sometimes heals very slowly. Thus avoiding scratching and trauma
decreases the amount of ulceration, though some ulceration will occur anyway.

There are some images of NDL lesions at

  http://tray.dermatology.uiowa.edu/DermImag.htm

No particularly good treatment seems to be known. Topical steroids (that is,
creams) are the most common first choice. The ulcerations usually heal if
cared for properly, and drastic measures are not called for in most cases.
William Biggs reports that skin grafts may be necessary in cases of severe
ulceration, but do not tend to give results that are cosmetically attractive.

Other treatments reported to help sometimes are oral aspirin, pentoxifylline,
dipyridamole, locally injected steroids, and systemic steroids. No one claims
to be able to predict what will work on any given patient, and often not much
of anything is effective. However, the ulcers usually heal if given
supportive treatment. Surgery should be avoided. Ineke van der Pol reports
finding relief in Chinese herbal treatments.

STEROID WARNING: locally injected and systemic steroids raise blood glucose
and cause severe problems regulating blood glucose. These should be used only
as a last resort. Topical steroids (creams and inhalers) cause no such
problems.

Note that treatment is not a medical necessity except for ulcerations and
infections. Otherwise, the purpose of treatment is to prevent ulcerations
and infections, decrease pain and itching, and improve the appearance.

NLD is the subject of occasional articles in scientific journals on diabetes
and on dermatology. Betsy Butler has researched the medical journals, finding
little beyond what I've reported above -- in her words, "no good answers".
_Therapy for Diabetes Mellitus and Related Disorders_, published by the ADA,
has a section on necrobiosis lipoidica diabeticorum and its treatment.

Ineke van der Pol has started a mailing list about NLD at
http://groups.yahoo.com/group/necrobiosis.

I thank the following people, especially Betsy, who posted the information
from which I derived this section:

    Betsy Butler Polley (who says sorry, she doesn't have any information
                         besides what's here)
    William Biggs <reddy_biggs(AT)msn.com>
    Tari M. Birch <tm_birch(AT)pnl.gov>
    Terence Griffin (who also says he doesn't have any other info)
    Bill Barner <barner(AT)mail.loc.gov>
    Ineke van der Pol <fluo(AT)chello.nl> (who has no further information
        but is happy to correspond about NLD if you wish)