Ulcerative necrobiosis lipoidica in the setting of anti–tumor necrosis factor-α and hydroxychloroquine treatment for rheumatoid arthritis

NL: necrobiosis lipoidica RA: rheumatoid arthritis INTRODUCTION Necrobiosis lipoidica (NL) is a rare, chronic granulomatous disease that affects the dermis with collagen degeneration. It can be associated with several conditions including diabetes mellitus, sarcoidosis, rheumatoid arthritis (RA), inflammatory bowel disease, autoimmune thyroiditis, and monoclonal gammopathy. NL typically develops in the third to fourth decade of life with a slight female predominance. In about one-third of cases, ulceration can develop as a complication, which poses unique treatment challenges to providers, as it is often recalcitrant to treatment. The literature suggests that antietumor necrosis factor-a medications represent a promising therapeutic strategy for ulcerative disease. Here we present a case of ulcerative NL that developed in the setting of etanercept and hydroxychloroquine treatment, and subsequently re-epithelialized with aggressive local treatment and discontinuation of etanercept.