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Frequently asked question: What is NLD?

Last updated: 07Aug96, added information on makeup to cover NLD scars

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NLD = necrobiosis lipoidica diabeticorum. A skin disease characterized
      by necrobiosis of connective and elastic tissue and 
      discolorization of skin. Common in diabetes.

Necrobiosis = Gradual degeneration and swelling of collagen bundles in 
      the dermis (skin).
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An endocrinologist speaks:

Necrobiosis is completely benign, except for the cosmetic aspects.

There is no good treatment. Many things have been tried, but nothing 
really works consistently as to recommend it.

It is usually bilateral, on both legs, "trying" to be symmetrical.

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>From the MHD FAQ on diabetes treatment:

Necrobiosis lipoidica diabeticorum (NLD) consists of oval plaques, 
usually on the lower legs. It may start as small red spots or raised 
areas, which develop a shiny, porcelain-like appearance. The plaques 
often turn a light color due to extracellular fat (the "lipoidica"). 
They are often itchy or painful. Typically the spots turn a brownish 
color, which fades slowly but is permanent.

NLD is not related to any other complication of diabetes. In particular, 
NLD does not presage eye, kidney or vascular problems.

NLD is much more common in diabetics, who account for perhaps 2/3 of all
cases. Many of the remainder develop diabetes, and NLD should be 
considered a warning sign of diabetes. Reports vary widely on exactly 
who is most at risk. About 1% of diabetics have some degree of NLD ... 
plus or minus 1%, depending on which report you read. Some reports say 
NLD occurs more often in young women, but some textbooks disagree.

The real dangers seem to be ulceration, infection, and the stress from 
the appearance. Ulceration sometimes occurs spontaneously, and often as 
a result of trauma.

Ulceration is often a result of scratching or trauma, and the ulceration 
from scratching sometimes heals very slowly. Thus avoiding scratching and 
trauma decreases the amount of ulceration, though some ulceration will 
occur anyway.

No particularly good treatment seems to be known. Topical steroids (that 
is,creams) are the most common first choice. The ulcerations usually 
heal if cared for properly, and drastic measures are not called for in 
most cases. William Biggs reports that skin grafts may be necessary in 
cases of severe ulceration, but do not tend to give results that are 
cosmetically attractive.

Other treatments reported to help sometimes are oral aspirin, 
pentoxifylline, dipyridamole, locally injected steroids, and systemic 
steroids. No one claims to be able to predict what will work on any 
given patient, and often not much of anything is effective. However, the 
ulcers usually heal if given supportive treatment. Surgery should be 
avoided.

STEROID WARNING: locally injected and systemic steroids raise blood 
glucose and cause severe problems regulating blood glucose. These should 
be used only as a last resort. Topical steroids (creams and inhalers) 
cause no such problems.

Note that treatment is not a medical necessity except for ulcerations 
and infections. Otherwise, the purpose of treatment is to prevent 
ulcerations and infections, decrease pain and itching, and improve the 
appearance.

NLD is the subject of occasional articles in scientific journals on 
diabetes and on dermatology. Betsy Butler has researched the medical 
journals, finding little beyond what I've reported above -- in her 
words, "no good answers". _Therapy for Diabetes Mellitus and Related 
Disorders_, published by the ADA, has a section on necrobiosis 
lipoidica diabeticorum and its treatment
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A DMer with NLD speaks:

I'm taking Trental, 400 mg 3 x day, and wearing support stockings every 
day.

I've seen dramatic results...no ulcerations or infections (which used
to be quite common) starting about 8 weeks after going on treatment.
The areas themselves have stopped "growing" (although they haven't
started shrinking yet), and they look much less "angry" (to use the
dermatologist's words). Also, no more pain, which used to come and go.

I swear by the Trental. It's considered experimental in treating the 
necrobiosis. Although it is FDA-approved to treat other conditions, the 
last I had heard, it wasn't considered an official treatment for 
necrobiosis. But, at least in my case, it's been extremely effective.

Trental is like STP for red blood cells. It allows the cells to slide 
past each other much more easily, thus minimizing clogging in the 
microvascular system, which causes the necrobiosis.
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Covering NLD Scars

A few of you asked me for the name of the leg/body makeup that I use on 
my NLD scars. It is called Dermablend Leg and Body Cover. I purchase it 
in Dillard's (a department store here in Florida); however, I've seen it 
in other department stores, also. My mother started using it on her
varicose veins after coming to visit me one summer. She initially 
purchased it in Macy's in New Jersey, but now she sometimes orders the 
full makeup line on QVC. They have other products for use on the face, 
etc., if you have scars and the like.

Here in Florida, the tube costs $12. There is also a setting powder to 
use that is supposed to make the makeup waterproof. I have the powder, 
but I can't remember what I paid for it. I haven't really found it to be 
totally waterproof--especially when my skin is scaly. It does seem to be 
waterproof for my Mom, though. I also use regular translucent powder 
instead of the setting powder, sometimes. I find the color blends a 
little better with my skin tone (pale, very, very, pale). Even with the 
makeup, you can still see that my legs are not "normal," but I feel the 
makeup looks better than the terrible, shocking, red ugliness I have 
running rampid on my shins. Anyway, I wear shorts all the time, and if I 
do get questions about my legs, I usually opt to string people along for 
a while with my skydiving accident story (embellished to the hilt, OK, 
totally made up really).
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