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Necrobiosis lipoidica (NL) is a chronic idiopathic gra-nulomatous skin disease often occurring in the setting of diabetes mellitus. Clinically, the lesions present as painful yellow-brown inflammatory plaques with raised borders and atrophic centres. NL typically involves the anterior lower leg and has a tendency to progress to ulceration and scarring. Treatment is often challenging and, to date, no standardized therapy has been proposed. We report here the case of a patient who was seen at a pre-ulcerative stage of NL that had not responded to conventional therapies. CASe RePORT A 27-year-old white man consulted for a slightly eroded le-sion of the external side of his left ankle, which had gradually enlarged becoming very painful. The lesion had been present for more than 3 years. His medical history was otherwise unre-markable, except for a history of type 1 diabetes mellitus since childhood. examination revealed atrophic, yellow-brown to red, telangiectatic plaque, 6×9 cm in size (Fig. 1a). The patient reported that the lesion had a tendency to ulcerate following minimal trauma, which clearly affected his quality of life. Skin biopsy from the lesion was consistent with NL, showing necrobiotic collagen with sclerosis and palisaded granuloma in the dermis. The dermal interstitial infiltrate consisted of his-tiocytes, multinucleated giant cells, lymphocytes, and plasma cells. Treat ment with topical tacrolimus and intralesional tri-amcinolone acetonide (5 mg/l) was unsuccessful. Given the young age of the patient, and based on previous reports arguing for efficacy of biological agents in NL (1, 2), it was decided to start therapy with infliximab. Chest X-ray, tuberculin test, hepatitis B and C and HIV serologies were all negative. The patient was therefore started on intravenous infliximab therapy, 5 mg/kg, associated for the first infusion with 200 mg hydrocortisone. The patient received a total of four infusions (at weeks 0, 2, 6, and 12). At his first post-treatment visit (week 2), the lesion had become painless. Complete wound healing was achieved at week 6 of infliximab therapy, with fading of the erythematous component, flattening of the margin and an excellent cosmetic result (Fig. 1b). The treatment was well tolerated with no noted side-effects. At 9-month follow-up, no relapse had been noted. DISCUSSION NL is a rare chronic inflammatory granulomatous skin disease of unknown origin. It is reported to occur more frequently in women than men (3, 4). The disease is often associated with diabetes mellitus, although treat ment of a patient's diabetes …

Treatment of Pre-ulcerative Necrobiosis Lipoidica with Infliximab