Volume 3, Issue 2, Pages (March 2017)

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Volume 3, Issue 2, Pages 127-130 (March 2017) Ulcerative necrobiosis lipoidica in the setting of anti–tumor necrosis factor-α and hydroxychloroquine treatment for rheumatoid arthritis Jennifer Albus Fehlman, MD, Nicole M. Burkemper, MD, Tricia A. Missall, MD, PhD JAAD Case Reports Volume 3, Issue 2, Pages 127-130 (March 2017) DOI: 10.1016/j.jdcr.2017.01.006 Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 1 Clinical examination at time of biopsy. A 3.0-cm firm erythematous plaque with multiple clean ulcerations tracking deep into the dermis of right lower leg, proximal to medial malleolus. JAAD Case Reports 2017 3, 127-130DOI: (10.1016/j.jdcr.2017.01.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 2 Representative section of the patient's punch biopsy shows a granulomatous inflammatory infiltrate, with histiocytes in the interstitium arranged in layered palisades, involving the deeper aspects of the reticular dermis. Foci of degenerated collagen are present among the layered palisades, and the infiltrate contains numerous plasma cells. Acid-fast bacillus and Gomori methenamine-silver stains were negative. (Hematoxylin-eosin stain; original magnification: ×40.) JAAD Case Reports 2017 3, 127-130DOI: (10.1016/j.jdcr.2017.01.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 3 Clinical examination at time of most recent follow-up. Atrophic pink plaque with prominent telangiectatic blood vessels throughout. No residual ulcerations. JAAD Case Reports 2017 3, 127-130DOI: (10.1016/j.jdcr.2017.01.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 4 Treatment algorithm designed for the patient. As the patient presented on hydroxychloroquine and etanercept, she was started on topical and local treatments. In addition another first-tier systemic medication, pentoxifylline was added to her regimen. Asterisk represents complete full review of symptoms. Consider blood testing including fasting blood glucose, Hemoglobin A1c, thyroid-stimulating hormone/T4, rheumatoid factor, serum protein electrophoresis/urine protein electrophoresis, and angiotensin converting enzyme inhibitor level. PDT, Photodynamic therapy; PUVA, psoralen ultraviolet A; TNF, tumor necrosis factor. Adapted from Sibbald and Alavi.2 JAAD Case Reports 2017 3, 127-130DOI: (10.1016/j.jdcr.2017.01.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions