An 88-year-old man over a 7-month period developed multiple yellow firm foc
ally ulcerative papules and nodules over his face, neck and forearms. Seven
skin biopsies showed a diffuse infiltrate of epithelioid histiocytes assoc
iated with areas of necrosis with neutrophilia. Two biopsies showed xanthog
ranulomatous foci, but cholesterol clefts, prominent giant cells or lymphoi
d aggregates were not evident. Necrosis with leukocytoclastic debris oversh
adowed the presence of hyaline necrobiosis. Ultrastructural examination and
oil red-o stains on frozen sections revealed focal lipid vacuoles within h
istiocytes. A paraprotein was detected in the patient's serum. This present
ation may represent a lipid and giant cell poor variant of necrobiotic xant
hogranuloma (NXG) and may potentially lead to a delay in diagnosis.