The role of anti-tumour necrosis factor in wound healing: A case report of refractory ulcerated necrobiosis lipoidica treated with adalimumab and review of the literature

Necrobiosis lipoidica is a chronic granulomatous disease historically associated with diabetes. Necrobiosis lipoidica commonly presents with erythematous papules or plaques on the anterior lower extremities, which can be ulcerated in up to 30% of patients. The pathophysiology of necrobiosis lipoidica is unknown but proposed to be predominantly linked to microangiopathy. No treatment option for necrobiosis lipoidica has shown consistent efficacy. Previous case reports have shown immune-modulating agents to be reasonable treatment options for ulcerative necrobiosis lipoidica. However, evidence for the tumour necrosis factor-alpha inhibitor, adalimumab, is limited and contradictory. We report a case of a 74-year-old type 2 diabetic female with a 2-year history of multiple ulcerated necrobiosis lipoidica plaques resistant to topical and systemic therapy. Treatment with adalimumab showed complete re-epithelization of all ulcers by week 28. Adalimumab may be an effective treatment option for ulcerated necrobiosis lipoidica that has failed traditional therapies. Further reports of adalimumab treatment of necrobiosis lipoidica and other chronic inflammatory wounds are needed.