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Necrobiosis Lipoidica — SCE Dermatology MCQ

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HardWound HealingNecrobiosis LipoidicaSCE Dermatology

A 65-year-old man with a longstanding history of necrobiosis lipoidica on his shins develops ulceration within one of his plaques. He has type 2 diabetes. Examination shows a yellowish waxy atrophic plaque with prominent telangiectasia and central ulceration on the left shin. What is the MOST important consideration before starting immunosuppressive treatment?

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Correct answer: A — Exclude underlying malignancy with biopsy

The correct answer is A, exclude underlying malignancy with biopsy. Necrobiosis lipoidica classically presents as a yellowish, waxy, atrophic plaque with prominent telangiectasia on the shin, but chronic ulceration within a longstanding plaque raises the possibility of malignant transformation, most commonly squamous cell carcinoma, occurring within the atrophic, poorly vascularised skin. Before commencing immunosuppressive treatment (topical or intralesional steroids, or biologic agents such as anti-TNF therapy), it is essential to biopsy the ulcer edge to exclude SCC, since immunosuppression could accelerate growth of an undiagnosed tumour and delay definitive oncological treatment. UK dermatology guidance specifically flags chronic ulceration in necrobiosis lipoidica as an indication for urgent suspicion and biopsy rather than empirical immunosuppression.

Reference: https://www.nice.org.uk/guidance/conditions-and-diseases/skin-conditions