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Medication

Medication Summary

Double-blind studies of the treatment of necrobiosis lipoidica with aspirin and dipyridamole have had varied results but overall have shown some beneficial effects from the therapy. The treatment is based on a theory that necrobiosis lipoidica results from platelet-mediated vascular occlusion or immune mechanisms that alter platelet survival.^[7]These drugs are thought to prolong platelet survival time and, hence, prevent further worsening of necrobiosis lipoidica.

Littler and Tschen described the successful use of pentoxifylline to treat a case of necrobiosis lipoidica.^[31]Pentoxifylline inhibits platelet aggregation and is believed to decrease blood viscosity by increasing fibrinolysis and red blood cell deformity.

Uncontrolled studies have suggested that ticlopidine,^[23]nicotinamide,^[24]clofazimine,^{[25, 26]}and perilesional heparin injections^[27]can benefit some patients with necrobiosis lipoidica.

Class Summary

These agents reduce complications resulting from increased blood viscosity.

Pentoxifylline (Trental)

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Pentoxifylline may alter the rheology of red blood cells, consequently reducing blood viscosity. It increases fibrinolysis and red blood cell deformity and also inhibits platelet aggregation.

Class Summary

These drugs inhibit platelet aggregation. The drugs are thought to prolong platelet survival time and, hence, prevent further worsening of necrobiosis lipoidica. They also help prevent cerebrovascular accidents and improve renal and systemic function.

Ticlopidine

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Ticlopidine is a second-line antiplatelet therapy for patients who fail aspirin therapy.

Class Summary

These agents may inhibit the synthesis of low-density lipoprotein and very-low-density lipoprotein. This inhibition results in a decrease of total plasma cholesterol. Nicotinamide, and not niacin or other niacin preparations, is a treatment option.^[24]Nicotinamide is the physiologically active form of niacin, vitamin B-3. Unlike niacin, nicotinamide in high doses does not lower lipid levels or cause flushing. However, it does exert significant anti-inflammatory effects.

NADH (Nicotinamide adenine dinucleotide)

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Nicotinamide moderates inflammatory reactions by inhibiting leukocytic chemotaxis and leukocytic release of lysosomal enzymes. It has been shown to inhibit lymphocytic transformation, antibody production, and mast cell degranulation.

Class Summary

Immunomodulators inhibit key factors responsible for the inflammatory response to tissue insult.

Clofazimine (Lamprene)

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Clofazimine is known to have anti-inflammatory properties in controlling erythema nodosum leprosum reactions, but its mechanism of action is unknown.

Class Summary

Anticoagulants inhibit the formation of blood clots resulting from blood disorders.

Heparin

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Heparin augments the activity of antithrombin III and prevents the conversion of fibrinogen to fibrin. It does not actively lyse, but it can inhibit further thrombogenesis. Heparin prevents the reaccumulation of clots after spontaneous fibrinolysis.

Class Summary

Retinoids regulate cell growth and differentiation.

Tretinoin topical (Avita, Retin-A, Tretin-X, Atralin)

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Tretinoin inhibits microcomedo formation and eliminates existing lesions. It makes keratinocytes in sebaceous follicles less adherent and easier to remove. The drug is available as a 0.025%, 0.05%, or 0.1% cream and as a 0.01% or 0.025% gel.

Questions

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Media Gallery

Typical presentation of necrobiosis lipoidica on the lower pretibial legs.
Red-brown plaque with yellow atrophic center on lower leg.

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Author

Cheryl J Barnes, MD Dermatologist, McIntosh Clinic, PC

Cheryl J Barnes, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Loretta S Davis, MD Professor and Chair, Department of Dermatology, Medical College of Georgia, Augusta University

Loretta S Davis, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for Physician Leadership, American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society, International Society for Clinical Densitometry, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle

Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Necrobiosis Lipoidica Medication

Medication Summary

Hemorheologic Agents