Necrobiosis lipoidica diabeticorum (NLD) is a rare skin complication of diabetes. Only 60- 70% of patients with NLD have diabetes with an incidence of only 0.3-0.7% among diabetics. The etiology of NLD is unknown; however, immune complex deposition with vascular changes is considered the most important factor. Currently there is no standard treatment for NLD. This case study clearly illustrates some of the challenges associated with diagnosis and treatment of this condition.

A 72- y.o. female with NIDDM presented with a 3-month history of a LLE ulceration, with a past medical history significant for PVD and HTN. The ulceration was noted after a fall at home.

Wound presented as a pre-tibial annular lesion with crusty edges and copious serous drainage, measuring 2.2 X 1.8 cm with unknown depth. BLE edema with no evidence of cellulitis or abnormality of periwound skin was noted and vascular assessment was WNL.

Local wound care consisted of; sharp and enzymatic debridement, hydrofiber and collagen dressings, negative pressure wound therapy, bilaminate skin application and edema control. All of which produced minimal results.

Wound dimensions continued to increase, a violaceous border became evident, and a diagnosis of NLD was made. In collaboration with patients Internist, HBO, systemic steroids and IV antibiotics were initiated. Considerable improvement was noted during the course of 28 HBO treatments, so on the 12th week of treatment an avascular dermal scaffold was applied. By the 12th week s/p application the wound had 100% epithelialization. (24 weeks of treatment)

In Conclusion the combination of systemic steroids, IV antibiotics, HBO, avascular dermal scaffold and LWC was successful. The success of this treatment emphasizes the role of hypoxia in the pathogenesis of the lesion. This combination of treatment may be a good solution for patients with NLD, which fail to respond to other therapeutic approaches.