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\begin{document}

\title{Atypical truncal necrobiosis lipoidica: When dermoscopy enlightens
clinics}



\author[1]{Marwa THABOUTI}%
\author[2]{Nadia Ghariani Fetoui}%
\author[1]{Oumaima Mani}%
\author[1]{Marouène Belkahla}%
\author[1]{Sana Mokni}%
\author[1]{Baderedine Sriha}%
\author[1]{Najet Ghariani}%
\author[3]{Mohamed Denguezli}%
\affil[1]{Farhat Hached University Hospital of Sousse}%
\affil[2]{Centre Hospitalier Universitaire Farhat Hached de Sousse}%
\affil[3]{Farhat Hached hospital, Sousse, Tunisia}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
Necrobiosis Lipoidica (NL) is a rare granulomatous skin condition
typically occurring in lower extremities. We report an atypical case of
NL and we highlight the role of dermoscopy in the diagnostic approach.%
\end{abstract}%



\sloppy


\textbf{Atypical truncal necrobiosis lipoidica: When dermoscopy
enlightens clinics}

\textbf{Marwa Thabouti(MD)*, Nadia Ghariani Fetoui(MD)*, Oumaina Mani
(MD)*, Marwane Ben Kahla (MD)*, Sana Mokni (MD)* Badreddine Sriha
(MD)**, Najet Ghariani (MD)*, Mohamed Denguezli (MD)*}

\textbf{* Dermatology Department, Farhat Hached Hospital, Sousse,
Tunisia.}

\textbf{** Anatomopathological Department, Farhat Hached Hospital,
Sousse, Tunisia.}

\textbf{Corresponding Autor:} Marwa Thabouti. Phone number:
0021650553815. Mail Adress: hebek2011@live.com

\textbf{No conflicts of interest to disclose.}

\textbf{No financial support.}

\textbf{No acknowledgement}

\textbf{Keywords:} Necrobiosis Lipoidica, Dermoscopy, diabetes mellitus

\textbf{``Written informed consent was obtained from the patient to
publish this report in accordance with the journal's patient consent
policy''}

Dear Editor;

Necrobiosis Lipoidica (NL) is a rare granulomatous skin condition
typically occurring in lower extremities. We report an atypical case of
NL and we highlight the role of dermoscopy in the diagnostic approach.

A 53-year-old lady, presented to our dermatology department with a
3-month history of a painful and pruritic skin lesion on the trunk. She
was known to have diabetes type 2 for the last 5 years, which was under
control with oral antidiabetic agents. There was no history of local
trauma or infection. Dermatologic examination showed an indurated,
erythematous plaque, giving rise to a serous fluide without atrophy,
ulceration or local inflammatory signs. The lesion was localized in the
intermammary area and included the upper inner part of the two
breasts\textbf{(Figure 1a)} . Systemic examination was unremarkable,
notably no fever or axillary lymphadenopathies. On dermoscopy, the
lesion showed uniformly distributed linear branched vessels, white
linear streaks and yellow structureless areas \textbf{(Figure 1b)} . Her
laboratory tests were within normal ranges, apart from hyperglycemia and
high glycated hemoglobin test. An Ultrasound scan showed a subcutaneous
fat thickening, with no collection, while mammography was read as
normal. The patient was prescribed a course of antibiotics for ten days
without any improvement. Histological examination of a skin biopsy
stained with hematoxylin and eosine showed sandwich-like horizontal
layers of necrobiotic collagen alternating with inflammatory cell
infiltrates of lymphocytes, histiocytes, multinucleated giant cells and
plasma cells. Stain for acid-fast bacilli was negative. The diagnosis of
truncal NL was made based on clinics, dermoscopic and histological
findings. The patient was treated with potent topical steroids once
daily. The skin lesion gradually resolved within two weeks
\textbf{(Figure 2a,2b)} .

NL is a rare chronic granulomatous dermatitis, which typically affects
young and middle-aged adults. It was described in association with
sarcoidosis, thyroid disorders, inflammatory bowel disorders, but most
frequently with diabetes mellitus \textbf{(1,2)} . NL affects 11\% to
87\% of diabetic patients \textbf{(3)} . It was described for the first
time by Oppenheim in 1929. Clinically, it is characterized by
well-defined erythematous papules, plaques or nodules. The center of the
plaque may show areas of atrophy and telangiectasia. Later, it may
develop ulceration in around 30\% of cases and rarely squamous cell
carcinoma \textbf{(4)} . It is located usually on the leg. Truncal
location, as seen in our patient, is very rare. Only one case was
reported in 2020 \textbf{(5)} . Dermoscopy is a non-invasive tool that
is very helpful in the diagnosis of such atypical cases. Three main
clues are suggestive of NL, notably linear branched vessels, a
background of yellow structureless areas and white linear streaks. Some
authors suggested a correlation between the different stages of the
disease and dermoscopic morphology of vessels, which presents at first
as curved lines, than as linear serpentine vessels and finally as linear
branches. To the best of our knowledge, our observation is the second
report of truncal NL in the literature. It highlights the important role
of dermoscopy in guiding the diagnosis of such atypical clinical
presentations.

\begin{enumerate}
\tightlist
\item
  Reid SD, Ladizinski B, Lee K, Baibergenova A, Alavi A. Update on
  necrobiosis lipoidica: a review of etiology, diagnosis, and treatment
  options. \emph{J Am Acad Dermatol.} 2013;\textbf{69} (5):783-791.
\item
  Clinical Features and Comorbidities of Patients with Necrobiosis
  Lipoidica with or Without Diabetes. Hashemi DA, Brown-Joel ZO,
  Tkachenko E, Nelson CA, Noe MH, Imadojemu S, Vleugels RA, Mostaghimi
  A, Wanat KA, Rosenbach M. JAMA Dermatol. 2019;155(4):455.
\item
  O'Toole EA, Kennedy U, Nolan JJ, Young MM, Rogers S, Barnes L.
  Necrobiosis lipoidica: only a minority of patients have diabetes
  mellitus. \emph{Br J Dermatol} . 1999;\textbf{140} (2):283-286.
\item
  Uva L, Freitas J, Soares de Almeida L, Vasques H, Moura C, Miguel D,
  Filipe P. Squamous cell carcinoma arising in ulcerated necrobiosis
  lipoidica diabeticorum. Int Wound J. 2015 Dec;12(6):741-3.
\item
  M. Alkhatieb, H. Mortada. Truncal necrobiosis lipoidica diabeticorum:
  A first case report. international Journal of Surgery Case Reports 77
  (2020) 311--313.
\end{enumerate}

\textbf{Figure 1: a:} indurated, erythematous plaque, without atrophy or
local inflammatory signs, \textbf{b:} red arrow: linear branched
vessels, black star: yellow structureless areas.

\textbf{Figure 2a, b:} The skin lesion resolved clinically and
dermoscopically.\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

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