Management: Support stockings, steroids
A lack of a clear etiology for NLD makes the treatment challenging. Leg rest may retard progression by alleviating lower extremity edema, and elastic support stockings may be used to protect against trauma (and thus, ulceration).4 Topical and intralesional steroids are helpful for inflammation, but be cautious when using them in atrophic lesions, as they may worsen atrophy. (Steroids should be avoided in lesions with advanced atrophy.) Topical steroids should be started with a low potency formulation (hydrocortisone 2.5% cream) and gradually advanced to a higher potency formulation (clobetasol propionate 0.05% cream).9
Various other therapeutic interventions have been shown to be effective, including tacrolimus ointment 0.1% applied twice daily for one month to prevent T-cell activation10 and antiplatelet aggregation therapy with aspirin and dipyridamole for 8 weeks.11 A multicenter prospective study showed an improvement of lesions in about two-thirds of patients when topical 0.005% psoralen was applied, followed by twice weekly ultraviolet-A irradiation for a mean of 22 exposures.12 Perilesional heparin injections of 5000 IU have also been shown to improve lesions by preventing micro-occlusion.13 Surgical therapies such as excision and grafting14 and pulse dye laser15 have shown promise in selected cases.
The prognosis
The prognosis of NLD is poor from a cosmetic point of view. Therefore, early treatment should be offered to retard its progression.
We advised our patient to wear elastic support stockings to protect the affected area from trauma. We also told her to apply moisturizing lotion 4 times a day, as well as topical hydrocortisone 2.5% ointment 2 times a day for 8 weeks.
CORRESPONDENCE Satyajeet Roy, MD, FACP, Cooper University Hospital,1103 North Kings Highway, Suite 203, Cherry Hill, NJ 08034; roy-satyajeet@cooperhealth.edu