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Necrobiosis lipoidica

Authors
Karolyn Wanat, MD
Misha Rosenbach, MD
Section Editor
Jeffrey Callen, MD, FACP, FAAD
Deputy Editor
Abena O Ofori, MD

INTRODUCTION

Necrobiosis lipoidica is a rare, chronic granulomatous disease of the skin. Skin involvement usually begins as red-brown or violaceous papules or nodules and progresses to yellow-brown, atrophic, telangiectatic plaques (picture 1A-E). The lower legs, especially the shins, are the most common sites of involvement. Ulceration is a common complication (picture 1F).

Necrobiosis lipoidica frequently occurs in association with diabetes mellitus, which accounts for the past use of the term "necrobiosis lipoidica diabeticorum" for this disease. The recognition that necrobiosis lipoidica also occurs in the absence of diabetes led to the change in terminology.

The treatment of necrobiosis lipoidica can be challenging. Topical or intralesional administration of corticosteroids is often used as initial therapy.

The clinical manifestations, diagnosis, and management of necrobiosis lipoidica will be reviewed here.

EPIDEMIOLOGY

Necrobiosis lipoidica is a rare disorder that primarily affects young and middle-aged adults but can also occur in children and the elderly. In a retrospective study of 171 patients with necrobiosis lipoidica, the average age of onset for patients with diabetes-associated necrobiosis lipoidica was 25 years, and the average age of onset for patients with nondiabetes-associated necrobiosis lipoidica was 46 years [1]. In a separate retrospective study of 100 patients with necrobiosis lipoidica, the median age at the time of evaluation was 52 years [2].

                         

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Literature review current through: Nov 2016. | This topic last updated: Thu Nov 10 00:00:00 GMT+00:00 2016.
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References
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  1. Muller SA, Winkelmann RK. Necrobiosis lipoidica diabeticorum. A clinical and pathological investigation of 171 cases. Arch Dermatol 1966; 93:272.
  2. Erfurt-Berge C, Dissemond J, Schwede K, et al. Updated results of 100 patients on clinical features and therapeutic options in necrobiosis lipoidica in a retrospective multicentre study. Eur J Dermatol 2015; 25:595.
  3. Erfurt-Berge C, Seitz AT, Rehse C, et al. Update on clinical and laboratory features in necrobiosis lipoidica: a retrospective multicentre study of 52 patients. Eur J Dermatol 2012; 22:770.
  4. Hammer E, Lilienthal E, Hofer SE, et al. Risk factors for necrobiosis lipoidica in Type 1 diabetes mellitus. Diabet Med 2016.
  5. Muller SA, Winkelmann RK. Necrobiosis lipoidica diabeticorum histopathologic study of 98 cases. Arch Dermatol 1966; 94:1.
  6. O'Toole EA, Kennedy U, Nolan JJ, et al. Necrobiosis lipoidica: only a minority of patients have diabetes mellitus. Br J Dermatol 1999; 140:283.
  7. Peyrí J, Moreno A, Marcoval J. Necrobiosis lipoidica. Semin Cutan Med Surg 2007; 26:87.
  8. Shall L, Millard LG, Stevens A, et al. Necrobiosis lipoidica: the footprint not the footstep. Br J Dermatol 1990; 123:47.
  9. De Silva BD, Schofield OM, Walker JD. The prevalence of necrobiosis lipoidica diabeticorum in children with type 1 diabetes. Br J Dermatol 1999; 141:593.
  10. Verrotti A, Chiarelli F, Amerio P, Morgese G. Necrobiosis lipoidica diabeticorum in children and adolescents: a clue for underlying renal and retinal disease. Pediatr Dermatol 1995; 12:220.
  11. Kelly WF, Nicholas J, Adams J, Mahmood R. Necrobiosis lipoidica diabeticorum: association with background retinopathy, smoking, and proteinuria. A case controlled study. Diabet Med 1993; 10:725.
  12. Jockenhöfer F, Kröger K, Klode J, et al. Cofactors and comorbidities of necrobiosis lipoidica: analysis of the German DRG data from 2012. J Dtsch Dermatol Ges 2016; 14:277.
  13. Reid SD, Ladizinski B, Lee K, et al. Update on necrobiosis lipoidica: a review of etiology, diagnosis, and treatment options. J Am Acad Dermatol 2013; 69:783.
  14. ENGEL MF, SMITH JG Jr. The pathogenesis of necrobiosis lipoidica. Necrobiosis lipoidica, a form fruste of diabetes mellitus. Arch Dermatol 1960; 82:791.
  15. Boateng B, Hiller D, Albrecht HP, Hornstein OP. [Cutaneous microcirculation in pretibial necrobiosis lipoidica. Comparative laser Doppler flowmetry and oxygen partial pressure determinations in patients and healthy probands]. Hautarzt 1993; 44:581.
  16. Ngo B, Wigington G, Hayes K, et al. Skin blood flow in necrobiosis lipoidica diabeticorum. Int J Dermatol 2008; 47:354.
  17. Evans CD, Pereira RS, Yuen CT, Holden CA. Anti-collagen antibodies in granuloma annulare and necrobiosis lipoidica. Clin Exp Dermatol 1988; 13:252.
  18. Holland C, Givens V, Smoller BR. Expression of the human erythrocyte glucose transporter Glut-1 in areas of sclerotic collagen in necrobiosis lipoidica. J Cutan Pathol 2001; 28:287.
  19. Oikarinen A, Mörtenhumer M, Kallioinen M, Savolainen ER. Necrobiosis lipoidica: ultrastructural and biochemical demonstration of a collagen defect. J Invest Dermatol 1987; 88:227.
  20. Gange RW, Black MM, Carrington P. Defective neutrophil migration in granuloma annulare, necrobiosis lipoidica, and sarcoidosis. Arch Dermatol 1979; 115:32.
  21. Nakajima T, Tanemura A, Inui S, Katayama I. Venous insufficiency in patients with necrobiosis lipoidica. J Dermatol 2009; 36:166.
  22. Alonso ML, Riós JC, González-Beato MJ, Herranz P. Necrobiosis lipoidica of the glans penis. Acta Derm Venereol 2011; 91:105.
  23. Andersen KE. Systemic sarcoidosis with necrobiosis lipoidica-like scalp lesions. Acta Derm Venereol 1977; 57:367.
  24. Dowling GB, Jones EW. Atypical (annular) necrobiosis lipoidica of the face and scalp. A report of the clinical and histological features of 7 cases. Dermatologica 1967; 135:11.
  25. el Sayed F, Elbadir S, Ferrere J, et al. Chronic balanitis: an unusual localisation of necrobiosis lipoidica. Genitourin Med 1997; 73:579.
  26. FORMAN L. Necrobiosis lipoidica diabeticorum of the scalp. Proc R Soc Med 1954; 47:658.
  27. GAETHE G. NECROBIOSIS LIPOIDICA DIABETICORUM OF THE SCALP. Arch Dermatol 1964; 89:865.
  28. Helander I, Niemi KM, Tyrkkö J. Atypical necrobiosis lipoidica of the face. Acta Derm Venereol 1978; 58:276.
  29. Jones EW. Necrobiosis lipoidica presenting on the face and scalp. An account of 29 patients and a detailed consideration of recent histochemical findings. Trans St Johns Hosp Dermatol Soc 1971; 57:202.
  30. Lecroq C, Thomine E, Boullie MC, Lauret P. [Atypical genital necrobiosis lipoidica]. Ann Dermatol Venereol 1984; 111:717.
  31. Lynch M, Callagy G, Mahon S, Murphy LA. Arcuate plaques of the face and scalp. Atypical necrobiosis lipoidica (ANL) of the face and scalp. Clin Exp Dermatol 2010; 35:799.
  32. Mackey JP. Necrobiosis lipoidica diabeticorum involving scalp and face. Br J Dermatol 1975; 93:729.
  33. Sawada Y, Mori T, Nakashima D, et al. Necrobiosis lipoidica of the scrotum. Eur J Dermatol 2011; 21:98.
  34. Shalhoop H. Round, pitting lesions on the lower leg. Necrobiosis lipoidica. JAAPA 2010; 23:14.
  35. Velasco-Pastor AM, Gil-Mateo MP, Martínez-Aparicio A, Aliaga-Boniche A. Necrobiosis lipoidica of the glans penis. Br J Dermatol 1996; 135:154.
  36. Vélez A, Martín-de-Hijas C, del-Río E, Ambrojo P. Ulcerated plaque of the face. Atypical necrobiosis lipoidica. Arch Dermatol 1994; 130:1433, 1436.
  37. Wantzin GL, Siim E, Medgyesi S. An unusual example of necrobiosis lipoidica affecting the face. Br J Plast Surg 1980; 33:61.
  38. Lowitt MH, Dover JS. Necrobiosis lipoidica. J Am Acad Dermatol 1991; 25:735.
  39. Gebauer K, Armstrong M. Koebner phenomenon with necrobiosis lipoidica diabeticorum. Int J Dermatol 1993; 32:895.
  40. Llajam MA. Koebner's phenomenon and necrobiosis lipoidica diabeticorum. Br J Clin Pract 1990; 44:765.
  41. Miller RA. Koebner phenomenon in a diabetic with necrobiosis lipoidica diabeticorum. Int J Dermatol 1990; 29:52.
  42. Patel GK, Harding KG, Mills CM. Severe disabling Köebnerizing ulcerated necrobiosis lipoidica successfully managed with topical PUVA. Br J Dermatol 2000; 143:668.
  43. Schumacher F, Schnyder UW. [Necrobiosis lipoidica and Koebner phenomenon]. Hautarzt 1991; 42:587.
  44. Alegre VA, Winkelmann RK. A new histopathologic feature of necrobiosis lipoidica diabeticorum: lymphoid nodules. J Cutan Pathol 1988; 15:75.
  45. Gibson LE, Reizner GT, Winkelmann RK. Necrobiosis lipoidica diabeticorum with cholesterol clefts in the differential diagnosis of necrobiotic xanthogranuloma. J Cutan Pathol 1988; 15:18.
  46. Pellicano R, Caldarola G, Filabozzi P, Zalaudek I. Dermoscopy of necrobiosis lipoidica and granuloma annulare. Dermatology 2013; 226:319.
  47. Conde-Montero E, Avilés-Izquierdo JA, Mendoza-Cembranos MD, Parra-Blanco V. Dermoscopy of necrobiosis lipoidica. Actas Dermosifiliogr 2013; 104:534.
  48. Bakos RM, Cartell A, Bakos L. Dermatoscopy of early-onset necrobiosis lipoidica. J Am Acad Dermatol 2012; 66:e143.
  49. Lallas A, Zaballos P, Zalaudek I, et al. Dermoscopic patterns of granuloma annulare and necrobiosis lipoidica. Clin Exp Dermatol 2013; 38:425.
  50. Balestri R, La Placa M, Bardazzi F, Rech G. Dermoscopic subpatterns of granulomatous skin diseases. J Am Acad Dermatol 2013; 69:e217.
  51. Souza FH, Ribeiro CF, Pereira MA, et al. Simultaneous occurrence of ulcerated necrobiosis lipoidica and granuloma annulare in a patient: case report. An Bras Dermatol 2011; 86:1007.
  52. Chiba T, Takahara M, Nakahara T, et al. Cutaneous sarcoidosis clinically mimicking necrobiosis lipoidica in a patient with systemic sarcoidosis. Ann Dermatol 2012; 24:74.
  53. Yoo SS, Mimouni D, Nikolskaia OV, et al. Clinicopathologic features of ulcerative-atrophic sarcoidosis. Int J Dermatol 2004; 43:108.
  54. Spicknall KE, Mehregan DA. Necrobiotic xanthogranuloma. Int J Dermatol 2009; 48:1.
  55. Goette DK. Resolution of necrobiosis lipoidica with exclusive clobetasol propionate treatment. J Am Acad Dermatol 1990; 22:855.
  56. Sparrow G, Abell E. Granuloma annulare and necrobiosis lipoidica treated by jet injector. Br J Dermatol 1975; 93:85.
  57. Patsatsi A, Kyriakou A, Sotiriadis D. Necrobiosis lipoidica: early diagnosis and treatment with tacrolimus. Case Rep Dermatol 2011; 3:89.
  58. Harth W, Linse R. Topical tacrolimus in granuloma annulare and necrobiosis lipoidica. Br J Dermatol 2004; 150:792.
  59. Barth D, Harth W, Treudler R, Simon JC. [Topical tacrolimus in necrobiosis lipoidica]. Hautarzt 2011; 62:459.
  60. Koura-Nishiura A, Yoneda K, Nakai K, et al. Clearance of atypical facial necrobiosis lipoidica with tacrolimus ointment. J Eur Acad Dermatol Venereol 2016; 30:383.
  61. De Rie MA, Sommer A, Hoekzema R, Neumann HA. Treatment of necrobiosis lipoidica with topical psoralen plus ultraviolet A. Br J Dermatol 2002; 147:743.
  62. Narbutt J, Torzecka JD, Sysa-Jedrzejowska A, Zalewska A. Long-term results of topical PUVA in necrobiosis lipoidica. Clin Exp Dermatol 2006; 31:65.
  63. McKenna DB, Cooper EJ, Tidman MJ. Topical psoralen plus ultraviolet A treatment for necrobiosis lipoidica. Br J Dermatol 2000; 143:1333.
  64. Patel GK, Mills CM. A prospective open study of topical psoralen-UV-A therapy for Necrobiosis lipoidica. Arch Dermatol 2001; 137:1658.
  65. Nguyen K, Washenik K, Shupack J. Necrobiosis lipoidica diabeticorum treated with chloroquine. J Am Acad Dermatol 2002; 46:S34.
  66. Durupt F, Dalle S, Debarbieux S, et al. Successful treatment of necrobiosis lipoidica with antimalarial agents. Arch Dermatol 2008; 144:118.
  67. Truchuelo T, Alcántara J, Fernández-Guarino M, et al. Photodynamic therapy for necrobiosis lipoidica is an unpredictable option: three cases with different results. Int J Dermatol 2013; 52:1589.
  68. Kosaka S, Kawana S. Case of necrobiosis lipoidica diabeticorum successfully treated by photodynamic therapy. J Dermatol 2012; 39:497.
  69. Berking C, Hegyi J, Arenberger P, et al. Photodynamic therapy of necrobiosis lipoidica--a multicenter study of 18 patients. Dermatology 2009; 218:136.
  70. De Giorgi V, Buggiani G, Rossi R, et al. Successful topical photodynamic treatment of refractory necrobiosis lipoidica. Photodermatol Photoimmunol Photomed 2008; 24:332.
  71. Heidenheim M, Jemec GB. Successful treatment of necrobiosis lipoidica diabeticorum with photodynamic therapy. Arch Dermatol 2006; 142:1548.
  72. Kreuter A, Knierim C, Stücker M, et al. Fumaric acid esters in necrobiosis lipoidica: results of a prospective noncontrolled study. Br J Dermatol 2005; 153:802.
  73. Gambichler T, Kreuter A, Freitag M, et al. Clearance of necrobiosis lipoidica with fumaric acid esters. Dermatology 2003; 207:422.
  74. Eberle FC, Ghoreschi K, Hertl M. Fumaric acid esters in severe ulcerative necrobiosis lipoidica: a case report and evaluation of current therapies. Acta Derm Venereol 2010; 90:104.
  75. Rhodes EL. Necrobiosis lipoidica treated with ticlopidine. Acta Derm Venereol 1986; 66:458.
  76. Eldor A, Diaz EG, Naparstek E. Treatment of diabetic necrobiosis with aspirin and dipyridamole. N Engl J Med 1978; 298:1033.
  77. Statham B, Finlay AY, Marks R. A randomized double blind comparison of an aspirin dipyridamole combination versus a placebo in the treatment of necrobiosis lipoidica. Acta Derm Venereol 1981; 61:270.
  78. Beck HI, Bjerring P, Rasmussen I, et al. Treatment of necrobiosis lipoidica with low-dose acetylsalicylic acid. A randomized double-blind trial. Acta Derm Venereol 1985; 65:230.
  79. Petzelbauer P, Wolff K, Tappeiner G. Necrobiosis lipoidica: treatment with systemic corticosteroids. Br J Dermatol 1992; 126:542.
  80. Taniguchi Y, Sakamoto T, Shimizu M. A case of necrobiosis lipoidica treated with systemic corticosteroid. J Dermatol 1993; 20:304.
  81. Boyd AS. Tretinoin treatment of necrobiosis lipoidica diabeticorum. Diabetes Care 1999; 22:1753.
  82. Heymann WR. Necrobiosis lipoidica treated with topical tretinoin. Cutis 1996; 58:53.
  83. Basaria S, Braga-Basaria M. Necrobiosis lipoidica diabeticorum: response to pentoxiphylline. J Endocrinol Invest 2003; 26:1037.
  84. Mensing H. [Clofazimine--therapeutic alternative in necrobiosis lipoidica and granuloma anulare]. Hautarzt 1989; 40:99.
  85. Rhodes EL. Fibrinolytic agents in the treatment of necrobiosis lipoidica. Angiology 1978; 29:60.
  86. Beattie PE, Dawe RS, Ibbotson SH, Ferguson J. UVA1 phototherapy for treatment of necrobiosis lipoidica. Clin Exp Dermatol 2006; 31:235.
  87. Attili SK, Dawe RS, Ibbotson SH. Ultraviolet A1 phototherapy: One center's experience. Indian J Dermatol Venereol Leprol 2016.
  88. Conte H, Milpied B, Kaloga M, et al. Treatment of pre-ulcerative necrobiosis lipoidica with infliximab. Acta Derm Venereol 2011; 91:587.
  89. Zeichner JA, Stern DW, Lebwohl M. Treatment of necrobiosis lipoidica with the tumor necrosis factor antagonist etanercept. J Am Acad Dermatol 2006; 54:S120.
  90. Buggiani G, Tsampau D, Krysenka A, et al. Fractional CO2 laser: a novel therapeutic device for refractory necrobiosis lipoidica. Dermatol Ther 2012; 25:612.
  91. Clayton TH, Harrison PV. Successful treatment of chronic ulcerated necrobiosis lipoidica with 0.1% topical tacrolimus ointment. Br J Dermatol 2005; 152:581.
  92. Binamer Y, Sowerby L, El-Helou T. Treatment of ulcerative necrobiosis lipoidica with topical calcineurin inhibitor: case report and literature review. J Cutan Med Surg 2012; 16:458.
  93. Maus EA. The importance of challenging your diagnosis even in straightforward cases. BMJ Case Rep 2012; 2012.
  94. Spenceri EA, Nahass GT. Topically applied bovine collagen in the treatment of ulcerative necrobiosis lipoidica diabeticorum. Arch Dermatol 1997; 133:817.
  95. Köstler E, Wollina U. Ulcerated necrobiosis lipoidica: a combined treatment approach with dermatosurgery and PUVA. Int J Low Extrem Wounds 2003; 2:243.
  96. Radakovic S, Weber M, Tanew A. Dramatic response of chronic ulcerating necrobiosis lipoidica to ultraviolet A1 phototherapy. Photodermatol Photoimmunol Photomed 2010; 26:327.
  97. Bouhanick B, Verret JL, Gouello JP, et al. Necrobiosis lipoidica: treatment by hyperbaric oxygen and local corticosteroids. Diabetes Metab 1998; 24:156.
  98. Weisz G, Ramon Y, Waisman D, Melamed Y. Treatment of necrobiosis lipoidica diabeticorum by hyperbaric oxygen. Acta Derm Venereol 1993; 73:447.
  99. Barde C, Laffitte E, Campanelli A, et al. Intralesional infliximab in noninfectious cutaneous granulomas: three cases of necrobiosis lipoidica. Dermatology 2011; 222:212.
  100. Dubin BJ, Kaplan EN. The surgical treatment of necrobiosis lipoidica diabeticorum. Plast Reconstr Surg 1977; 60:421.
  101. Kavala M, Sudogan S, Zindanci I, et al. Significant improvement in ulcerative necrobiosis lipoidica with hydroxychloroquine. Int J Dermatol 2010; 49:467.
  102. Schofield C, Sladden MJ. Ulcerative necrobiosis lipoidica responsive to colchicine. Australas J Dermatol 2012; 53:e54.
  103. Mahé E, Zimmermann U. [Significant improvement in ulcerative necrobiosis lipoidica with doxycycline]. Ann Dermatol Venereol 2011; 138:686.
  104. Noz KC, Korstanje MJ, Vermeer BJ. Ulcerating necrobiosis lipoidica effectively treated with pentoxifylline. Clin Exp Dermatol 1993; 18:78.
  105. Littler CM, Tschen EH. Pentoxifylline for necrobiosis lipoidica diabeticorum. J Am Acad Dermatol 1987; 17:314.
  106. Benedix F, Geyer A, Lichte V, et al. Response of ulcerated necrobiosis lipoidica to clofazimine. Acta Derm Venereol 2009; 89:651.
  107. Kukreja T, Petersen J. Thalidomide for the treatment of refractory necrobiosis lipoidica. Arch Dermatol 2006; 142:20.
  108. Barouti N, Cao AQ, Ferrara D, Prins C. Successful treatment of ulcerative and diabeticorum necrobiosis lipoidica with intravenous immunoglobulin in a patient with common variable immunodeficiency. JAMA Dermatol 2013; 149:879.
  109. Batchelor JM, Todd PM. Treatment of ulcerated necrobiosis lipoidica with intravenous immunoglobulin and methylprednisolone. J Drugs Dermatol 2012; 11:256.
  110. Aslan E, Körber A, Grabbe S, Dissemond J. [Successful therapy of ulcerated necrobiosis lipoidica non diabeticorum with cyclosporine A]. Hautarzt 2007; 58:684.
  111. Smith K. Ulcerating necrobiosis lipoidica resolving in response to cyclosporine-A. Dermatol Online J 1997; 3:2.
  112. Stanway A, Rademaker M, Newman P. Healing of severe ulcerative necrobiosis lipoidica with cyclosporin. Australas J Dermatol 2004; 45:119.
  113. Stinco G, Parlangeli ME, De Francesco V, et al. Ulcerated necrobiosis lipoidica treated with cyclosporin A. Acta Derm Venereol 2003; 83:151.
  114. Darvay A, Acland KM, Russell-Jones R. Persistent ulcerated necrobiosis lipoidica responding to treatment with cyclosporin. Br J Dermatol 1999; 141:725.
  115. Reinhard G, Lohmann F, Uerlich M, et al. Successful treatment of ulcerated necrobiosis lipoidica with mycophenolate mofetil. Acta Derm Venereol 2000; 80:312.
  116. Hu SW, Bevona C, Winterfield L, et al. Treatment of refractory ulcerative necrobiosis lipoidica diabeticorum with infliximab: report of a case. Arch Dermatol 2009; 145:437.
  117. Kolde G, Muche JM, Schulze P, et al. Infliximab: a promising new treatment option for ulcerated necrobiosis lipoidica. Dermatology 2003; 206:180.
  118. Leister L, Körber A, Dissemond J. [Successful treatment of a patient with ulcerated necrobiosis lipoidica non diabeticorum with adalimumab]. Hautarzt 2013; 64:509.
  119. Zhang KS, Quan LT, Hsu S. Treatment of necrobiosis lipoidica with etanercept and adalimumab. Dermatol Online J 2009; 15:12.
  120. Heng MC, Song MK, Heng MK. Healing of necrobiotic ulcers with antiplatelet therapy. Correlation with plasma thromboxane levels. Int J Dermatol 1989; 28:195.
  121. Kalus AA, Chien AJ, Olerud JE. Diabetes mellitus and other endocrine diseases. In: Fitzpatrick's Dermatology in General Medicine, 8th ed, Goldsmith LA, Katz SI, Gilchrest BA. (Eds), McGraw-Hill, 2012. Vol 2, p.1840.
  122. Beljaards RC, Groen J, Starink TM. Bilateral squamous cell carcinomas arising in long-standing necrobiosis lipoidica. Dermatologica 1990; 180:96.
  123. Clement M, Guy R, Pembroke AC. Squamous cell carcinoma arising in long-standing necrobiosis lipoidica. Arch Dermatol 1985; 121:24.
  124. Gudi VS, Campbell S, Gould DJ, Marshall R. Squamous cell carcinoma in an area of necrobiosis lipoidica diabeticorum: a case report. Clin Exp Dermatol 2000; 25:597.
  125. Imtiaz KE, Khaleeli AA. Squamous cell carcinoma developing in necrobiosis lipoidica. Diabet Med 2001; 18:325.
  126. Lim C, Tschuchnigg M, Lim J. Squamous cell carcinoma arising in an area of long-standing necrobiosis lipoidica. J Cutan Pathol 2006; 33:581.
  127. McIntosh BC, Lahinjani S, Narayan D. Necrobiosis lipoidica resulting in squamous cell carcinoma. Conn Med 2005; 69:401.
  128. Santos-Juanes J, Galache C, Curto JR, et al. Squamous cell carcinoma arising in long-standing necrobiosis lipoidica. J Eur Acad Dermatol Venereol 2004; 18:199.