title: Anti-TNFα treatment for recalcitrant ulcerative necrobiosis lipoidica diabeticorum: A case report and review of the literature.
abstract: BACKGROUND
  Necrobiosis lipoidica diabeticorum (NLD) is a rare degenerative connective tissue disorder associated with diabetes mellitus, which usually presents with red papules or plaques with raised edges and occasional ulceration. Ulcerating NLD is notoriously difficult to treat. We present a young patient with ulcerative NLD who was successfully treated with the anti-TNFα agent infliximab. Case presentation is followed by a review of therapeutic TNFα blockade in NLD.
  
  
  METHODS
  A 17-year old woman with type 1 diabetes since the age of 8, presented with a long-standing and extensively ulcerated and infected NLD lesion on her left shin. After achieving better glycemic control and treating her for infection of the wound, several NLD treatments failed to help, including corticosteroids and hyperbaric oxygen. She was treated successfully with 4 monthly sessions of 5mg/kg body weight intravenous infliximab, achieving complete resolution of ulceration.
  
  
  CONCLUSIONS
  A multitude of available treatments have been suggested for NLD over the past decades, based on two axes, one through wound healing and the other through immunosuppression. Anti-TNFα agents are relatively new drugs that brought a revolution in chronic inflammatory diseases and have been on the rise as novel potential treatments for NLD. Three out of the five available anti-TNFα agents have been safely tested so far, both topically and systematically, with mostly favorable results.
  
  
  CONCLUSIONS
  Intravenous infliximab was successful in the treatment of recalcitrant ulcerating NLD in our patient. Taken together with an increasing number of similar reports revealing a pathogenetic role of TNFα in NLD, we suggest that anti-TNFα agents are promising drugs in the management of this condition.
authors.affiliation: First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece. Electronic address: dimitris.bassoulis@gmail.com.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Basoulis
authors.affiliation: First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece. Electronic address: po_fragiadaki@yahoo.gr.
authors.forename: Kalliopi
authors.initials: K
authors.lastname: Fragiadaki
authors.affiliation: First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece. Electronic address: ntentol@med.uoa.gr.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Tentolouris
authors.affiliation: First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece. Electronic address: psfikakis@med.uoa.gr.
authors.forename: Petros P
authors.initials: PP
authors.lastname: Sfikakis
authors.affiliation: First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece. Electronic address: rjd@otenet.gr.
authors.forename: Alexander
authors.initials: A
authors.lastname: Kokkinos
mesh_terms: D000293:Adolescent; D001786:Blood Glucose; D003879:Dermatologic Agents / Q000627:therapeutic use*; D003922:Diabetes Mellitus, Type 1 / Q000150:complications; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D000069285:Infliximab / Q000627:therapeutic use*; D007275:Injections, Intravenous; D007866:Leg / Q000473:pathology; D009335:Necrobiosis Lipoidica / Q000209:etiology / Q000473:pathology / Q000517:prevention & control*; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D001786:Blood Glucose; D003879:Dermatologic Agents; D007004:Hypoglycemic Agents; C439524:TNF protein, human; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab
keywords: Anti-TNFα agents; Necrobiosis lipoidica diabeticorum; Type 1 diabetes mellitus