A 77-year-old woman attended clinic for review of longstanding necrobiosis lipoidica. She reported a tender lesion on the left lower leg that had developed over 2 months. This had not responded to treatment with topical steroids, unlike all previous necrobiosis lipoidica-related ulcerations. On examination, a 15×15 mm tender ulcerating nodule was evident within an area of clinical chronic quiescent necrobiosis lipoidica (Fig 1). This patient originally presented to our department 9 years previously, with a 3×4 cm well-circumscribed pink-brown plaque with central atrophy and telangiectasia on the left shin. Histology demonstrated a palisading and interstitial granulomatous dermatitis and was supportive of the clinical diagnosis of necrobiosis lipoidica. Past medical history included hypertension and hypothyroidism but not diabetes. Over subsequent years, the plaque on the left shin enlarged and two smaller plaques developed on the right shin. Intermittent areas of ulceration were successfully managed with potent topical steroids (± occlusion). Topical tacrolimus 0.1% had also been beneficial at reducing inflammation in non-ulcerated areas. A 4 mm incisional punch biopsy was performed on the new nodular lesion. This demonstrated well differentiated squamous cell carcinoma (Fig 2). The nodule was subsequently excised with 4 mm clinical margins and repaired with a split skin graft.
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