Laser therapies for the treatment of necrobiosis lipoidica: literature review and own experience

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INTRODUCTION

Lipoid necrobiosis is a rare chronic skin disorder of vascular-metabolic origin belonging to the group of localized cutaneous lipoidoses, characterized by collagen degeneration [1–3]. Lipoid necrobiosis most commonly affects the skin of the anterior surface of the lower legs. In the early stage, the eruptions appear as small reddish-brown firm papules, which progress into yellowish-pink atrophic plaques with visible telangiectasias on their surface.

Lipoid necrobiosis occurs in 0.3%–1.2% of patients with diabetes mellitus. Currently, there are very few publications reporting the prevalence of this condition in the general population [2]. The mean age of onset for lipoid necrobiosis is 45 years in patients with diabetes mellitus and 52 years among patients without diabetes mellitus. Lipoid necrobiosis is more frequently associated with type 1 diabetes mellitus [4]. Women are affected by lipoid necrobiosis 2–3 times more often than men [5].

Lipoid necrobiosis was first described in 1929 by Austrian dermatovenereologist Moritz Oppenheim as dermatitis atrophicans lipoidica diabetica, and in 1932, Erich Urbach renamed the condition necrobiosis lipoidica diabeticorum. Starting in 1935, researchers repeatedly reported cases of lipoid necrobiosis in patients without diabetes mellitus, and by 1960, Rollins and Winkelmann [6] proposed renaming the disease to necrobiosis lipoidica. Today, the term lipoid necrobiosis encompasses all clinical variants of this disease, regardless of whether it is associated with diabetes mellitus.

The diagnosis is often established clinically, but biopsy with subsequent histological examination may be required to differentiate it from conditions such as granuloma annulare, sarcoidosis, and necrobiotic xanthogranuloma [7]. Key histological features include endothelial cell accumulation, thickened blood vessel walls extending into the deep dermal layers. Such changes are also observed in diabetic microangiopathy. In patients with diabetes mellitus, lipoid necrobiosis typically demonstrates palisading granulomas bordered by areas of necrobiosis and degenerated collagen [8]. Histological specimens from the inflammatory rim at the plaque edge reveal scattered palisaded and interstitial granulomatous dermatitis with layered granulomatous inflammation parallel to the skin surface, spanning the entire dermis and localized to interlobular connective tissue septa. Granulomas consist of histiocytes, lymphocytes, plasma cells, and eosinophils; they surround collagen degeneration zones and lack significant central mucin deposition compared to granuloma annulare [1]. Nerve fiber degeneration and epidermal atrophy are frequently observed.

The management of patients with lipoid necrobiosis begins with blood tests, including fasting glucose, glycated hemoglobin, and a glucose tolerance test. All these are performed to screen for diabetes mellitus and assess glycemic control in patients with diabetes mellitus. Given the frequent association of lipoid necrobiosis with thyroid pathology, it is also advisable to measure the concentrations of thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), and anti-thyroid peroxidase antibodies. The presence of any other signs of autoimmune conditions, such as additional cutaneous or joint symptoms, should prompt a comprehensive evaluation for rheumatological disease [2].

Although many methods have been described for the treatment of necrobiosis lipoidica, none have proven to be universally effective. Compression therapy helps reduce edema and alleviate symptoms in patients with venous disorders of the lower extremities and lymphedema [4, 9]. Strict glycemic control has not been shown to improve symptoms in the short term, but likely helps slow disease progression. There are also reports of lipoid necrobiosis resolution in patients following pancreatic transplantation [8].

First-line therapy includes topical glucocorticoids and intralesional glucocorticoid injections into the area of the distal inflammatory rim during disease progression [7]. Some studies have shown greater efficacy of topical tacrolimus. Moreover, unlike glucocorticoids, calcineurin inhibitors do not carry the risk of skin atrophy as a side effect [10, 11]. There is experience with systemic use of calcineurin inhibitors, dapsone, fumaric acid esters, and cyclosporine [12, 13]. Anti-inflammatory agents such as chloroquine and hydroxychloroquine have also been used in the treatment of necrobiosis lipoidica with positive effects [14].

Tumor necrosis factor (TNF) plays a significant role in granuloma development. Adalimumab, infliximab, and etanercept directly bind to TNF-α, inhibiting its activity. Etanercept and infliximab have been reported to be effective as monotherapy for ulcerative forms of necrobiosis lipoidica [13].

Experts worldwide have employed various physiotherapeutic methods in the treatment of necrobiosis lipoidica. Long-wave UVA-1 phototherapy has demonstrated efficacy in the study by Attili et al. [15], where 4/13 patients showed positive skin changes and two experienced lesion regression, as well as in the study by Beattie et al. [16], where all patients (n = 6) reported positive skin changes after completing the treatment course.

The application of PUVA therapy in lipoid necrobiosis has been well described. For example, Narbutt et al. [17], when studying the efficacy of PUVA therapy in 10 patients, observed nearly complete remission in all study participants after an average of 47 ultraviolet A radiation sessions with systemic psoralen administration.

Another treatment method utilizing ultraviolet light is photodynamic therapy. This approach employs photosensitizing agents (methyl aminolevulinate and aminolevulinic acid). Photodynamic therapy has demonstrated efficacy in studies conducted by research groups led by Attili [15], Kaae [18], and Truchuelo [19].

The experience of using laser technologies, such as fractional CO₂ lasers, pulsed dye lasers, and intense pulsed light (IPL) therapy, has been described. IPL therapy is of particular scientific interest to us.

We present the results of our own observations on the efficacy of IPL therapy in treating lipoid necrobiosis, including cases with concomitant diabetes mellitus.

CASE DESCRIPTION

Case 1

A 26-year-old woman was diagnosed with necrobiosis lipoidica without comorbidities.

Comprehensive examination revealed no type 1/2 diabetes mellitus, impaired glucose tolerance, or thyroid pathologies.

The cutaneous lesion localized on the anterior surface of the right lower leg presented as a single 4 cm diameter plaque with yellowish-pink coloration, a prominent bright pink inflammatory peripheral ridge, central atrophy, and telangiectasias (Fig. 1). Following the diagnosis of necrobiosis lipoidica, the patient was prescribed topical glucocorticoids and calcineurin inhibitors. No positive changes in the cutaneous process were observed during prolonged therapy, prompting the decision to initiate an IPL therapy course.

 

Fig. 1. Female, 26 years old, diagnosed with lipoid necrobiosis, without concomitant pathology: a ― before treatment; b ― after treatment. From the archive of the V.A. Rakhmanov Clinic of Skin and Venereal Diseases, 2025. The photograph is published for the first time.

 

Ten IPL radiation sessions were performed over 9 months. After the third session, the patient reported reduced telangiectasias, flattening of the peripheral ridge, and resolution of hypersensitivity in the lesion area.

The IPL protocol is detailed in Table 1, with parameters adjusted according to methods described by Medeiros et al. [20], Cunha et al. [21], patient-reported sensations, and clinical response severity.

 

Table 1. Scheme of treatment intense pulsed light therapy (clinical case 1)

Number and date of procedure	Procedure parameters	First pass	Second pass
1 (16.11.2023)	Filter, nm Duration, ms Energy, J/cm2	560 7 16.7	510 7 15.8
2 (07.12.2023)	Filter, nm Duration, ms Energy, J/cm2	560 7 17.7	510 7 16.7
3 (11.01.2024)	Filter, nm Duration, ms Energy, J/cm2	560 6 17.0	510 6 16.3
4 (08.02.2024)	Filter, nm Duration, ms Energy, J/cm2	560 6 17.8	510 6 17.0
5 (07.03.2024)	Filter, nm Duration, ms Energy, J/cm2	560 8 19.6	510 8 20.4
6 (01.04.2024)	Filter, nm Duration, ms Energy, J/cm2	560 9 21.4	510 10 21.8
7 (22.04.2024)	Filter, nm Duration, ms Energy, J/cm2	560 9 21.4	510 10 21.8
8 (13.05.2024)	Filter, nm Duration, ms Energy, J/cm2	560 9 21.4	510 10 21.8
9 (10.06.2024)	Filter, nm Duration, ms Energy, J/cm2	560 9 21.4	510 10 21.8
10 (04.07.2024)	Filter, nm Duration, ms Energy, J/cm2	560 8 18.6	510 8 18.6

 

Post-treatment outcomes included decreased lesion erythema, further ridge flattening, improved tissue elasticity, complete telangiectasia resolution, and symptom relief (see Fig. 1). Pretreatment soft tissue ultrasound revealed a 3 mm lesion depth, reduced to 1 mm after IPL therapy.

Case 2

A 22-year-old woman was diagnosed with lipoid necrobiosis at age 8 and type 1 diabetes mellitus at the age of 4 years.

Long-term treatment with topical glucocorticoids and calcineurin inhibitors, along with local PUVA therapy, showed no positive effect.

The skin lesion localized on the dorsum of the left foot presented as a single yellowish plaque measuring 5 cm in diameter, with a bright pink peripheral ridge and central telangiectasias (Fig. 2). The patient reported periodic ulceration of the lesion due to trauma.

 

Fig. 2. Female, 22 years old, diagnosed with lipoid necrobiosis and type 1 diabetes mellitus: a ― before treatment; b ― after treatment. From the archive of the V.A. Rakhmanov Clinic of Skin and Venereal Diseases, 2025. The photograph is published for the first time.

 

IPL therapy parameters were as follows: first pass: 560 nm filter, 8 ms pulse duration, 17.5 J/cm² energy; second pass: 510 nm filter, 7 ms pulse duration, 15.8 J/cm² energy. Immediate resolution of telangiectasias was observed after the first procedure (see Fig. 2).

Case 3

A 64-year-old man with established diagnoses of type 2 diabetes mellitus and lipoid necrobiosis

presented with widespread skin involvement. The lesions consisted of round, dark pink plaques measuring 2–4 cm in diameter, with central clearing, peripheral infiltrated ridges, and firm consistency (Fig. 3).

 

Fig. 3. Male, 64 years old, diagnosis of lipoid necrobiosis with type 2 diabetes mellitus: a, b ― before treatment; c ― after treatment. From the archive of the V.A. Rakhmanov Clinic of Skin and Venereal Diseases, 2025. The photograph is published for the first time.

 

A decision was made to initiate treatment of one lesion as a test area (see Fig. 3). Parameters for the first procedure: first pass: 560 nm filter, 7 ms pulse duration, 17.7 J/cm² energy; second pass: 510 nm filter, 7 ms pulse duration, 17.7 J/cm² energy. Parameters for the second procedure: first pass: 690 nm filter, 6 ms pulse duration, 15.6 J/cm² energy; second pass: 560 nm filter, 7 ms pulse duration, 17.7 J/cm² energy; third pass: 510 nm filter, 7 ms pulse duration, 17.7 J/cm² energy.

After 4 weeks of therapy, positive changes were observed as flattening of the peripheral ridge and lightening of the central portion (see Fig. 3).

Case 4

A 42-year-old woman was diagnosed with lipoid necrobiosis.

Comprehensive examination revealed no type 1/2 diabetes mellitus, impaired glucose tolerance, or thyroid pathologies.

The cutaneous lesion was localized on the anterior surface of the right lower leg, presenting as a single yellowish-pink oval plaque measuring 4 cm in diameter with firm consistency; central telangiectasias were visualized within the lesion (Fig. 4). Long-term topical therapy showed no improvement.

 

Fig. 4. Female, 42 years old, diagnosis of lipoid necrobiosis: a ― before treatment; b ― on the background of treatment (4 treatments). From the archive of the V.A. Rakhmanov Clinic of Skin and Venereal Diseases, 2025. The photograph is published for the first time.

 

The patient underwent four IPL therapy sessions, with parameters detailed in Table 2.

 

Table 2. Scheme of treatment intense pulsed light therapy (clinical case 4)

Number and date of procedure	Procedure parameters	First pass	Second pass
1 (16.05.2024)	Filter, nm Duration, ms Energy, J/cm2	560 7 15.8	510 7 16.7
2 (06.06.2024)	Filter, nm Duration, ms Energy, J/cm2	560 7 15.8	510 7 16.7
3 (27.06.2024)	Filter, nm Duration, ms Energy, J/cm2	560 8 17.5	510 10 20.6 (narrow window)
4 (25.07.2024)	Filter, nm Duration, ms Energy, J/cm2	560 8 17.5	510 8 18.5

 

Treatment is ongoing. Interim positive outcomes include focal lightening of the plaque and resolution of telangiectasias (see Fig. 4).

DISCUSSION

LASER (Light Amplification by the Stimulated Emission of Radiation) is an acronym denoting the amplification of light through stimulated emission. Laser radiation is monochromatic, meaning the emitted light consists of a single wavelength determined by the medium (filter) of the laser system through which the light passes. When interacting with the skin, laser radiation can be absorbed, reflected, or scattered. The absorption of laser radiation by tissues depends on chromophores—target molecules in the skin. The theory of selective photothermolysis, introduced by Richard Rox Anderson and John Parrish in 1983, played a pivotal role in advancing laser surgery. This theory explains the mechanism, enabling controlled targeting of specific skin structures without significant damage to surrounding tissues [22]. By selecting the appropriate laser system medium (filter, wavelength), the radiation can influence collagen and microcirculatory vessels, precisely the structures altered in lipoid necrobiosis.

We conducted a review of scientific publications for the last five years, sourced from PubMed and Google Scholar. Out of 124 analyzed publications, 2 articles were selected. Studies describing physiotherapeutic methods for lipoid necrobiosis, phototherapy, CO₂ laser, and pulsed dye laser applications were excluded from the review.

In 2020, Medeiros et al. [20] reported the use of IPL therapy for the treatment of necrobiosis lipoidica in a 24-year-old patient without comorbidities. The treatment course consisted of 7 procedures, with intervals ranging 5–13 weeks between sessions. The following parameters were used: wavelength range of 540–580 nm, pulse duration of 10–40 ms (single-pulse mode), and energy fluence of 16–20 J/cm². Changes in the color of the peripheral ridge and central atrophy became noticeable after the first procedure. Subsequent positive changes were observed, including reduction of telangiectasias, flattening of the peripheral ridge, and partial resolution of central atrophy.

In 2021, Cunha et al. [21] described the application of IPL therapy in necrobiosis lipoidica in a 50-year-old patient with a 23-year history of diabetes mellitus. Over the previous 5 years, the patient had developed symmetrical yellowish plaques with central atrophy and erythematous rims on the anterior surfaces of both shins. After 2 years of unsuccessful treatment with topical glucocorticoids and PUVA therapy, the patient was initiated on an IPL therapy course. Thirteen procedures were performed over 14 months using combined wavelengths of 420–1100 nm, single-pulse mode with 10 ms duration, and energy fluence of 10–20 J/cm² to target vascular lesions (oxyhemoglobin absorption) and collagen restoration. The treatment protocol involved two sequential steps: longer wavelengths were first applied to deeper collagen structures, followed by shorter wavelengths targeting superficial vascular structures. The patient reported improvement after the second procedure, with significant clinical outcomes including reduced telangiectasias, decreased erythema intensity, and flattening of the peripheral ridge.

CONCLUSION

Currently, 15 patients are undergoing IPL therapy as part of our study, and patient enrollment is ongoing. All participants have already demonstrated positive intermediate outcomes.

Based on our experience, selective photothermolysis offers broad therapeutic potential for various skin conditions. The adjustability of wavelengths, pulse duration, and energy allows clinicians to tailor parameters to individual cases, accounting for skin type, lesion depth and size, avoiding epidermal damage and severe side effects.

Patients diagnosed with lipoid necrobiosis often have chronic comorbidities, leading them to apply numerous therapeutic approaches, both topical and systemic, as well as physiotherapeutic procedures. Currently, none of the existing treatment methods proposed by the scientific community have demonstrated absolutely positive and sustained efficacy. Given the ability of intense pulsed light to regulate collagenogenesis and influence the microcirculatory bed, we believe IPL therapy warrants further and more in-depth study for patients with lipoid necrobiosis.

ADDITIONAL INFORMATION

Authors' contributions. N.P. Teplyuk, E.A. Morozova ― scientific editing of the text, revision of the original text; V.A. Rogozina ― collection and analysis of literary sources, preparation and writing of the text. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Consent for publication. The patient gave her written voluntary informed consent for the publication of the clinical case and photographic materials in this journal. The scope of the published data has been agreed with the patient.

Funding sources. No funding.

Disclosure of interests. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Statement of originality. When conducting the research and creating this work, the authors did not use previously published information (text, illustrations, data).

Access to data. The editorial policy regarding data sharing does not apply to this work, and no new data was collected or created.

Generative AI. Generative AI technologies were not used for this article creation.

Provenance and peer-review. This work was submitted to the journal on its own initiative and reviewed according to the usual procedure. The review included two external reviewers and the scientific editor of the publication.

About the authors

Elena A. Morozova

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: doc.elene@mail.ru
ORCID iD: 0000-0001-5826-5018
SPIN-code: 4437-3800

MD, Cand. Sci. (Medicine)

Russian Federation, Moscow

Natalia P. Teplyuk

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: Teplyukn@gmail.com
ORCID iD: 0000-0002-5800-4800
SPIN-code: 8013-3256

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Moscow

Varvara A. Rogozina

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Author for correspondence.
Email: varvara.rgzn@gmail.com
ORCID iD: 0000-0002-5471-6130
SPIN-code: 3505-7408
Russian Federation, Moscow

References

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