Ulcerative necrobiosis lipoidica on the left upper arm and right lower leg

A 75-year-old Japanese man was referred to us and complained of multiple ulcers on his left forearm and right lower leg. He underwent amputation of the right second toe with unknown cause at the age of 18. Since then, he had suffered from recurring skin ulcers on the left forearm and right lower leg for nearly 60 years. At the initial visit, irregular wellcircumscribed brown atrophic aspects were seen on the left arm and from the dorsum of the right foot to the anterior surface of the right lower leg. The center of the atrophic region contained many ulcers with dilated capillaries and crust. On laboratory examination, the results of a chest roentgenogram and angioechogram were normal, and the only abnormal finding was a slightly elevated level of CRP in plasma. Fungus and acid-fast bacillus cultures were negative. A histopathological examination revealed a palisading granuloma surrounding degenerated collagen fibers, which extended through the deep dermis into subcutaneous tissue. The ulcerative lesions were refractory to various conventional treatments.