Unusual presentation and successful treatment of necrobiosis lipoidica in a 15-year-old girl

Necrobiosis lipoidica (NL) is a rare, granulomatous skin disease with a predilection for diabetic patients. NL can present both histopathologically and clinically in a similar fashion to other granulomatous dermatoses such as granuloma annulare, necrobiotic xanthogranuloma, and cutaneous sarcoidosis. When NL is suspected in patients without glucose intolerance, affirmative diagnosis can be difficult, and other comorbidities may be probed, as NL has been associated with conditions such as hypertension, dyslipidemia, and thyroid disorders. Familial disease has also been reported.In the following case report, we discuss a 15-year-old girl who presented with a new, single, pink atrophic plaque of the right pretibial region. Biopsy showed palisaded granulomatous inflammation within the dermis, absent dermal mucin, and rare multinucleated giant cells. This histopathologic description combined with the clinical context led to the diagnosis of necrobiosis lipoidica. The patient developed another similar lesion on the left anterior shin over the next 1.5 years which was also approached as necrobiosis lipoidica. The lesions were treated with intralesional triamcinolone acetonide and topical tacrolimus. Both lesions are now resolved with only mild atrophy of the affected areas. To date, the patient’s labs have shown no evidence of glucose intolerance, hyperlipidemia, or thyroid disorder.