Ulcerated necrobiosis lipoidica to a teenager with diabetes mellitus and obesity.

Many skin lesions are associated with diabetes mellitus (DM) type 1 or 2, due to the use of antidiabetics or to metabolic and endocrine disorders caused by this disease. Necrobiosis lipoidica (NL) occurs more frequently in patients with DM. Painful ulcerations may occur on NL areas in about 20-25% of the cases and usually they are related to trauma. We present the case of a teenager, male, 17-year-old, having NL with multiple plaques, some of them spontaneously ulcerated after about 33 months of onset. He is known with type 1 DM from 2.5 years and the NL preceding the diagnosis of diabetes mellitus with about six months, presented erythematous-infiltrative skin plaques, some ulcerated for about three months, interesting both shins. Based on clinical, histopathological and paraclinical examinations, we established the following diagnoses: ulcerated NL, type 1 DM, moderate mixed dyslipidemia, class I obesity; commissural candidiasis, juvenile acne. Under treatment with Pentoxifyllinum, Sulodexidum, Ketotifenum and topical therapy with 0.2% Hyaluronic acid two months later, we have managed to heal two of the three ulcerated plaques and of the third has become superficial. We applied 0.5% Fluocortolonum on non-ulcerated plaques recording an improvement after two weeks of treatment. NL is a skin disease with a predilection for the shins, more frequent in patients with diabetes and is a part of palisading granulomatous dermatitis, which leads to skin atrophy. NL is found in the 0.3-1.2% of diabetic patients and is rare in children with diabetes (0.006%). It is more common in the patients with type 1 DM. The onset is in the third decade in diabetic patients and in the fourth decade in non-diabetics. There is no consensus concerning the treatment of NL, and the results are often modest. Antiplatelet agents, corticosteroids (local and general), immunomodulatory drugs, cyclins, wide synthetic antipaludics, heparin, Thalidomide are used. NL treatment is very difficult, especially in the ulcerated forms. Many of the drugs listed have proven efficacy only in isolated cases. Studies are necessary on large series of patients to determine the optimal therapy of NL.

Disseminated granuloma annulare: study on eight cases.

Granuloma annulare (GA) is classified as localized, generalized/disseminated, subcutaneous, and perforating types. The studies show connection with diabetes mellitus, lipidic metabolic disorders, malignant diseases, thyroid disorders, infections (HBV, HCV, HIV). We performed a retrospective study between 2010-2011, regarding disseminated GA (GAD), and the relationship between GAD and other comorbidities. We clinically and histologically diagnosed eight cases of GAD. The patients were also investigated for the diagnosis of associated diseases. The treatment included topical corticosteroids, antihistamines, Calcipotriol/Betamethasone, Tacrolimus 0.03%, Pentoxifylline, Hydroxychloroquine. Therapeutic response was assessed one month and three months after hospitalization. Our patients were five women and three men, aged 46-68 years, mean age 57.25 years, with a disease history of one year and a half (between three months and four years). The lesions occurred in the upper extremities (eight cases), distal extremities (three cases), cervical area (two cases), and trunk (five cases). In seven cases, we found annular appearance and one patient had disseminated small papules eruption. Associated pathology was diabetes mellitus type II (five cases), overweight and obesity (five cases), dyslipidemia (three cases), hypothyroidism (one case), rheumatoid arthritis (one case), external ear canal basal carcinoma (one case). Although there is controversy regarding the relationship between GAD and associated diseases, it is accepted that it is significantly associated with diabetes mellitus, also found in our study in five out of eight cases. We noticed obvious improvements after local and general treatment. It is confirmed that GAD is prevalent in women, over 40-year-old. GAD is often associated with diabetes and dyslipidemia, therefore it is necessary to investigate patients in this direction. The histopathological exam is essential for an accurate confirmation of GA.