What is the treatment for necrobiosis diabeticorum?

Treatment of Necrobiosis Lipoidica Diabeticorum

There is no standardized treatment that completely reverses the atrophic changes associated with necrobiosis lipoidica diabeticorum (NLD), but several therapeutic approaches have shown benefit, with platelet-rich plasma (PRP) demonstrating marked enhancement in wound healing for NLD-associated recalcitrant wounds. 1

First-line Approaches

Glycemic Control

• Optimizing diabetes management with individualized HbA1c goals is essential, as some NLD lesions may improve with better glycemic control 2
• Poor glycemic control can impair wound healing and exacerbate existing lesions

Topical and Intralesional Therapies

• Topical and intralesional corticosteroids for active, inflammatory lesions
• Consider administering intradermal steroids to perilesional areas surrounding active lesions to halt progression 3
• For ulcerated NLD:
  • Proper wound cleansing and debridement of necrotic tissue is necessary
  • Appropriate dressing selection based on wound characteristics:
    • Continuously moistened saline gauze or hydrogels for necrotic wounds
    • Alginates or foams for exudative wounds
    • Films or hydrocolloids for dry wounds

Advanced Therapies for Recalcitrant Cases

Platelet-Rich Plasma (PRP)

• PRP has shown marked enhancement in wound healing for NLD-associated recalcitrant wounds without adverse effects 1
• After PRP application, advanced dressings should be used until complete closure of the lesion

Pentoxifylline

• Recommended dosage: 400 mg three times daily for at least 6 months 4
• Mechanism: Improves blood flow and decreases red cell and platelet aggregation
• Clinical improvement typically follows this timeline:
  • 1 month: Lesions stop enlarging
  • 3 months: Initial signs of healing
  • 6 months: Near resolution of lesions

Protease Modulating Matrix

• PROMOGRAN has shown success in treating hard-to-heal NLD ulcers that failed to respond to other dressing regimens 5
• Complete healing has been documented after 8 weeks of treatment in cases where other approaches failed over years

Wound Care Principles for Ulcerated NLD

• Debridement using sharp, enzymatic, autolytic, or biological methods to remove necrotic tissue and biofilm
• Biofilm management is essential (present in 90% of chronic wounds)
• Consider antimicrobial dressings and collagen matrix dressings
• For extensive or infected ulcers, follow wound care principles:
  • Obtain deep tissue specimens for culture before starting antibiotics
  • Select appropriate antibiotics based on infection severity if clinically infected
  • Avoid antibiotics for clinically uninfected wounds to prevent resistance

Important Clinical Considerations

• NLD affects approximately 0.3-0.7% of diabetic patients 2, 5
• The inflammatory infiltrate of NLD extends from the lesion into apparently normal surrounding skin 3
• NLD is frequently associated with other chronic complications of diabetes, including limited joint mobility 3
• Cutaneous anesthesia is usually present in NLD lesions due to local destruction of cutaneous nerves by the inflammatory process 3
• NLD often cycles through stages of activity and inactivity, making management challenging 5

Treatment Algorithm

1. Establish optimal glycemic control
2. For non-ulcerated, active inflammatory lesions:
   • Start with topical/intralesional corticosteroids
   • Consider pentoxifylline 400 mg TID for at least 6 months
3. For ulcerated NLD:
   • Appropriate wound care with debridement and dressings
   • Consider PRP for recalcitrant wounds
   • Try protease modulating matrix (PROMOGRAN) for wounds failing conventional therapy
4. Monitor for signs of infection and treat appropriately if present
5. Continue therapy until resolution and maintain glycemic control to prevent recurrence