Cath Lab Digest

Many people with diabetes develop skin manifestations as a result of having the disease. In some instances, such skin problems may be the first sign that the patient has diabetes. Proper recognition is the key to successful treatment, but making the proper diagnosis can be difficult. Some conditions may have similar characteristics and presentations. With this in mind, test your diagnostic acumen with the following case.
A 64-year-old female with non-insulin-dependent diabetes mellitus came into the office with right and left leg ulcerations. The patient’s past medical history is significant for peripheral vascular disease, Charcot foot deformity, hypertension, pulmonary sarcoidosis and thyroid condition. She says the ulcerations just popped up a couple of weeks ago. The patient says the skin on her legs is itchy and it looked like a dull red area at first presentation. She reports no pain and admits that her blood sugar is not in very good control.

What Is The Differential Diagnosis?
1. Necrobiosis lipoidica diabeticorum
2. Diabetic neuropathic ulceration
3. Bullous pemphigoid
4. Venous stasis ulceration

A Closer Look At Possible Answers
1. Necrobiosis lipoidica diabeticorum (NLD) is the correct answer. Besides the common neuropathic and arterial type of ulcer, NLD can also occur in patients with diabetes. These ulcerations usually occur most often in women under the age of 40. These types of lesions typically occur over the front of the lower extremities and are oval and irregular in presentation. These ulcerations are reddish-brown plaques with central atrophy and translucent telangiectasias. NLD usually starts as a dull red raised area, but after a little while, you’ll see that the skin appears shiny with a violet border. Sometimes, NLD is itchy and painful.
A minor trauma usually precedes the development of these ulcerations. Between 60 to 70 percent of patients with NLD have diabetes, but only about .3 percent of diabetic patients are affected by NLD.