(CS-108) Fish Skin Graft for the treatment of hard-to-heal ulcerative necrobiosis lipoidica diabeticorum

Introduction: Patients with Diabetes Mellitus are at risk for cutaneous pathological conditions. Typical conditions are well-managed in the clinical setting; however, there are sparse treatment options for less common conditions¹. Necrobiosis lipoidica diabeticorum (NLD) is a rare, chronic condition with unknown causes. NLD is a granulomatous disease associated with collagen degeneration, abnormal thickening of blood vessel walls, and lipid deposition, often resulting in ulceration and, if untreated squamous cell carcinoma². Fish skin graft (FSG) treats acute and chronic wounds. FSG's inherent omega-3 fatty acid content may positively affect inflammatory ulcerations like NLD. Therefore, the purpose of this case was to investigate FSG for the treatment of ulcerative NLD.

Methods: The patient is a 45-year-old male diagnosed in 2019 by his dermatologist with ulcerative NLD. Prior to diagnosis, the patient received several failed treatments. The patient had no treatment with oral steroids; however, his dermatologist treated him with oral antibiotics and topical corticosteroids, which failed to close the ulcerations.

Upon presentation, the patient had a violaceous plaque with open bilateral ulcers on the anterior aspect of his lower extremities that had been left open to the air. The ulcerations presented with moderate serous drainage, and the patient stated he was experiencing progressive and intense pain. He had not taken pain medication. Initial treatment consisted of topical tacrolimus 0.1% applied daily. Due to the increased inflammation, treatment included 1,200 mg of omega-3 fatty acids per day and the application of FSG.

Results: The patient received six weekly applications of the FSG, which successfully healed the bilateral ulcerations (Initial Total Surface Area = 42 cm); 6 cm (L) x 7 cm (W) x 0.3 (D)). There were linear reductions in wound width, length, and depth, with the most notable changes at week five. Interestingly, the patient stated that his pain levels dropped significantly after the first application of the FSG.

Discussion: Patients with diabetes have significant morbidity that often results in pathology, including ulcerations. While there are treatment options for common conditions, sparse options exist for rare manifestations. FSG is a novel biological option that augments tissue regeneration due to biochemical and biomechanical properties preserved during patented processing^3,4. In our patient, the FSG graft was able to heal long-standing ulcerative NLD and reduce pain. Future studies should investigate our findings in a large representative population.