Quality-of-life impairment in patients with livedoid vasculopathy

Occlusive cutaneous vasculopathies as cause of chronic ulcers

The term occluding vasculopathies covers a large number of different conditions. These often manifest as skin ulcers. Occluding vasculopathies should be considered in the differential diagnosis of leg ulcers. The term "occlusive vasculopathies" encompasses pathophysiologically related entities that share structural or thrombotic obliteration of small cutaneous vessels. In this article, we will focus on livedoid vasculopathy with and without antiphospholipid syndrome and calciphylaxis with differentiation from hypertonic leg ulcer as the most relevant differential diagnoses of leg ulcer. The term also includes vascular occlusion, for example due to oxalate or cholesterol embolism, and septic vasculopathy. This often leads to acral ulceration and is therefore not a differential diagnosis with classic leg ulcers. It will not be discussed in this article. Occlusive vasculopathy may be suspected in the presence of the typical livedo racemosa or (non-inflammatory) retiform purpura as a sign of reduced cutaneous perfusion in the wound area. Inflammatory dermatoses, especially vasculitides, must be differentiated. This is achieved by histopathological evaluation of a tissue sample of sufficient size and depth taken at the appropriate time. In addition, specific laboratory parameters, particularly coagulation parameters, can support the diagnosis.

Okkludierende kutane Vaskulopathien als Ursachen chronischer Unterschenkelulzerationen

Unter den Begriff der okkludierenden Vaskulopathien fällt eine Reihe unterschiedlicher Krankheitsbilder. Diese manifestieren sich an der Haut häufig mit Ulzerationen. Gerade bei Ulzerationen der Unterschenkel sollten okkludierende Vaskulopathien in die differenzialdiagnostischen Überlegungen einbezogen werden. Der Begriff „okkludierende Vaskulopathien“ umfasst pathophysiologisch verwandte Entitäten, die eine strukturelle oder thrombotische Obliteration von kleinsten Hautgefäßen gemein haben. In diesem Artikel wird vor allem auf die Livedovaskulopathie mit und ohne Antiphospholipidsyndrom sowie die Calciphylaxie mit Abgrenzung zum Ulcus cruris hypertonicum als die relevantesten Differenzialdiagnosen von Unterschenkelulzerationen eingegangen. Der Begriff umfasst auch Gefäßverschlüsse, beispielsweise durch Oxalat oder Cholesterinembolie, sowie die septische Vaskulopathie. Diese führt häufig zu akralen Ulzerationen und stellt somit keine Differenzialdiagnose zum klassischen Ulcus cruris dar. Sie wird daher in diesem Artikel nicht behandelt.

Der Verdacht einer okkludierenden Vaskulopathie kann über die typische Livedo racemosa beziehungsweise die (nichtinflammatorische) retiforme Purpura als Zeichen der kutanen Minderdurchblutung in der Wundumgebung gestellt werden. Entzündliche Dermatosen, insbesondere Vaskulitiden, müssen differenzialdiagnostisch abgegrenzt werden. Dies geschieht zum Teil klinisch und durch die histopathologische Beurteilung einer Gewebeprobe, die in ausreichender Größe und Tiefe sowie zum richtigen Zeitpunkt entnommen werden muss. Ergänzend können spezifische Laborparameter, insbesondere die Gerinnungsdiagnostik, die Diagnosestellung unterstützen.

A Refractory Livedoid Vasculopathy Accompanied by Methylene Tetrahydrofolate Reductase Gene Polymorphism Successfully Treated with Hyperbaric Oxygen Therapy

Livedoid vasculopathy (LV) is a chronic coagulation disorder characterized by recurrent, painful ulcers on the lower extremities. Methylene tetrahydrofolate reductase (MTHFR) gene polymorphism is associated with coagulopathy. Therapeutic options usually include anti-inflammatory or immunosuppressive agents. However, the condition is still highly challenging to manage and no consensus over the first-line treatment for LV exists. Furthermore, when LV is accompanied with MTHFR gene polymorphism, clinical presentations could be more severe and resistant to treatment. We report a case of refractory LV accompanied by MTHFR gene polymorphism, which was successfully treated with hyperbaric oxygen therapy (HBOT). A 63-year-old female patient presented with multiple painful ulcers, atrophie blanches, and retiform purpura on both lower legs and feet. Histopathologic findings were compatible with LV. LV was diagnosed based on these clinicopathological findings. Following the diagnosis, we treated the patient with pentoxifylline, aspirin, systemic corticosteroid, antihistamine, and antibiotics. In spite of six-month treatment, the skin lesions did not improve; hence, HBOT was performed. It was performed at 2.0 absolute atmosphere for 120 minutes each time, three times a week. After 4 sessions, the ulcers began to heal and after 13 sessions, the skin lesions almost healed. During the eight-month follow-up period, the skin ulcers did not recur and the symptoms remained stable. Additionally, it was confirmed that she had MTHFR gene polymorphism after a genetic test. In conclusion, we wish to provide evidence regarding the effectiveness of HBOT and suggest that HBOT might be a considerable treatment option in refractory LV.

A comprehensive review on pathogenesis, associations, clinical findings, and treatment of livedoid vasculopathy

Livedoid vasculopathy (LV) is a thrombo-occlusive vasculopathy that involves the dermal vessels. Clinically, it is characterized by the presence of painful purpuric ulcers on the lower extremities. Histopathologically, it shows intraluminal fibrin deposition and thrombosis, segmental hyalinization, and endothelial proliferation. It is important to notice that the term "atrophie blanche" is descriptive and it includes not only patients with LV but also patients with a combination of vasculitis and vasculopathy, that is, LV and medium-sized vasculitis such as cutaneous polyarteritis nodosa (PANc). Diagnosis is based on a proper clinicopathological correlation, excluding the main differential diagnosis and considering vasculitis as a mimicker or concomitant diagnosis. Coagulation disorders must also be studied although they are not found in all LV. Its frequency is reviewed as well. Treatment of LV is challenging, and different therapies have been attempted. Among them, pain management, wound care, control of cardiovascular risk factors, and both antiplatelets and anticoagulants, mostly rivaroxaban, are the main therapies used. These different therapies as well as their degree of evidence are reviewed.

Livedoid vasculopathy: A review with focus on terminology and pathogenesis

Livedoid vasculopathy (LV) is a rare thrombotic vasculopathy of the dermis characterized by painful, relapsing ulcers over the lower extremities. Diagnosis is challenging due to the overlap in clinical appearance and nomenclature with other skin disorders. Treatment selection is complicated by poor understanding of the pathogenesis of LV and lack of robust clinical trials evaluating therapy efficacy. The terminology and pathophysiology of LV are reviewed here, along with its epidemiology, clinical and histologic features, and treatment options. A diagnostic pathway is suggested to guide providers in evaluating for comorbidities, referring to appropriate specialists, and choosing from the available classes of therapy.

Livedoid vasculopathy and peripheral neuropathy: A retrospective cohort study of 55 Chinese patients and literature review

Livedoid vasculopathy (LV) is a thrombo-occlusive vascular disease with an uncertain aetiology. In addition to cutaneous manifestations, LV patients may develop peripheral neuropathy. This study aimed to examine features of peripheral neuropathy in Chinese LV patients. We retrospectively reviewed and analysed the clinical data of 55 LV patients treated at Peking Union Medical College Hospital and conducted a literature review of peripheral neuropathy in LV patients. The incidence of peripheral neuropathy in our cohort was 12.73%. Among the seven patients with neuropathy, five were women and two were men. Median age at enrollment and disease onset in these patients was 27.29 and 22.57 years, respectively. Mean time from the appearance of cutaneous manifestations to the development of neurological symptoms was 38.67 months. Peripheral neuropathy was generally refractory to treatment, asymmetric in the distal extremities, and slowly progressive. The main symptom was numbness; hypoesthesia and neuromuscular manifestations occurred occasionally. The proportion of patients reporting seasonal worsening of symptoms was significantly higher in LV patients with peripheral neuropathy than in LV patients without neuropathy (P < .05). Peripheral neuropathy is a potential complication of LV. LV patients with peripheral neuropathy require long-term follow-up.

Baricitinib is potentially effective in the treatment of refractory livedoid vasculopathy

Background

Livedoid vasculopathy is a rare, chronic, and recurrent disease with limited effective treatments. Its etiopathogenesis remains incompletely understood. Baricitinib, a selective Janus kinase 1 and 2 inhibitor, has been used to treat rheumatoid arthritis and could reduce the disease severity in patients with livedoid vasculopathy.

Methods

We retrospectively observed eight patients who received 2 mg/day of baricitinib for the treatment of refractory livedoid vasculopathy. We evaluated their clinical scores before and after treatment to determine its effectiveness and safety.

Results

Improvement in livedoid vasculopathy was observed with significant regression in the clinical scores after baricitinib treatment. The mean clinical scores were 7.0 ± 1.6 and 1.4 ± 1.2 before and after baricitinib treatment, respectively (P <0.01). Furthermore, six out of the eight patients achieved a clinical score of 0 or 2 after treatment. These scores indicated remission. Clinical findings, including erythema, ulceration, and pain, improved in all the patients. The remission times ranged from 3 to 13 weeks, with a mean remission time of 7.75 ± 3.45 weeks. There were no reports of adverse events in any patient.

Conclusions

Our study showed that baricitinib treatment was safe and could significantly relieve the signs and symptoms of livedoid vasculopathy. However, randomized controlled studies should be conducted to confirm these results.

Livedoid vasculopathy - A diagnostic and therapeutic challenge

Livedoid vasculopathy is a rare, chronic-recurrent occlusive disorder in the microcirculation of dermal vessels. The clinical appearance is characterized by Livedo racemosa, painful ulceration, located in the distal parts of the lower extremities, followed by healing as porcelain-white, atrophic scars, the so-called Atrophie blanche. Different conditions that can promote a hypercoagulable state, such as inherited and acquired thrombophilias, autoimmune connective-tissue diseases and neoplasms, can be associated with livedoid vasculopathy. Therefore, livedoid vasculopathy is currently considered to be a coagulation disorder, clearly distinguished from inflammatory vasculitis. Although there are hints to hypercoaguability and secondary inflammation, pathophysiology is not completely understood. Diagnosis is made by synopsis of history, clinical and histopathological findings. Early and adequate therapy is essential to maintain life quality and avoid irreversible complications. Better understanding of molecular mechanisms is required to establish appropriate therapy regimens. This article presents the current state of knowledge about livedoid vasculopathy and proposes an algorithmic approach for diagnosis and therapy.

Efficacy and safety of intravenous immunoglobulin for treating refractory livedoid vasculopathy: a systematic review

Introduction:

Intravenous immunoglobulin (IVIG) was reported to be the third most used monotherapy in livedoid vasculopathy (LV). There is currently a lack of randomized controlled clinical trials and no standardized therapeutic regimen for IVIG therapy in LV.

Methods:

We performed a systematic review of the efficacy and safety of IVIG in treating patients with LV using PubMed, Cochrane, and Embase databases.

Results:

Eighty LV patients from 17 articles were included, receiving IVIG therapy at a dose of 1–2.1 g/kg body weight every 4 weeks. The effective rate of IVIG therapy in LV patients was 95% (76/80) in published studies, showing a good clinical response for resolution of pain, skin ulcerations, and neurological symptoms, and reducing the dependence on glucocorticoids and immunosuppressive agents. IVIG therapy was well tolerated, and no severe adverse events were observed.

Conclusion:

Overall, to a certain degree, IVIG is probably a safe and effective treatment alternative for refractory LV patients, which still need to be confirmed by large-scale randomized controlled clinical trials.

Rivaroxaban for treatment of livedoid vasculopathy: A systematic review

Rivaroxaban is a direct inhibitor of activated coagulation factor X and competitively targets factor Xa via reversible binding. We conducted a systematic review of the efficacy and safety of rivaroxaban for treatment of livedoid vasculopathy (LV) by searching the PubMed, Cochrane and Embase databases. A total of 22 articles and 1 registered clinical trial were identified in the search of which 13 were included. The studies included 73 LV patients receiving rivaroxaban therapy (10-20 mg per day). Overall, 60 patients (82.2%) had responses to therapy, achieving remission of both pain and ulceration. Few adverse effects were observed. Thus, the consensus of the clinical evidence is that rivaroxaban is a well-tolerated and effective treatment for LV. However, this still needs to be confirmed by large prospective and/or case control studies.

Intravenous Immunoglobulin Therapy in Livedoid Vasculopathy: Retrospective Observation of Clinical Outcome and Patient's Activity Level

Background

Livedoid vasculopathy (LV) is a rare disease characterized by livedo racemosa, atrophie blanche, ulcerations, and severe pain. Low molecular weight heparins and rivaroxaban can be used in LV-patients. In addition, intravenous immunoglobulins (IVIG) have been described as treatment-option.

Objectives

Objective was to investigate the therapeutic effect of IVIG on ulcer, pain and restrictions in daily life.

Methods

Thirty-two LV-patients who received IVIG at the Department of Dermatology Tübingen between 01/2014 and 06/2019 were identified. Twenty-five of these patients were available for further follow up and were included in the study. Patients were interviewed using a questionnaire focusing on the course of the disease, symptoms, and subjective response to IVIG-treatment.

Results

Twenty-five patients were included in the study (mean follow up: 28.9 months). Patients received an average of 6.8 cycles (range 1-45) of IVIG during the observed period.

Significant improvements were seen regarding skin findings, pain, and limitation of daily activities. Complete remission of symptoms was observed in 68% of patients. Good tolerability of IVIG was shown in 92%.

Conclusions

A good therapy response regarding ulceration, pain, and daily life restrictions with good tolerability was demonstrated for IVIG (2 g/kg bodyweight over 5 days).

Systemic therapies for leg ulcers

Successful management of patients with leg ulcers requires identification of the underlying etiology, with subsequent initiation of causal treatment, if feasible. Supplementary measures of first choice include stage-adjusted wound treatment, usually combined with compression therapy. The significance of systemic drugs has been the subject of controversial debate, depending on the underlying cause of the condition. The present review article is therefore meant to highlight current aspects of systemic drug therapies for the treatment of leg ulcers associated with chronic venous insufficiency, peripheral arterial disease, livedoid vasculopathy, vasculitis, necrobiosis lipoidica, calciphylaxis and pyoderma gangrenosum. In summary, the majority of therapeutic options presented herein are used off-label. While systemic drugs are promising options for the more common types of wounds such as venous, mixed or arterial leg ulcers, they do not represent the current standard of treatment. By contrast, systemic agents play a key role in the management of many of the other disorders presented herein. These agents primarily include immunomodulatory and rheological drugs used to expedite wound healing.

Characteristics, risk factors and treatment reality in livedoid vasculopathy - a multicentre analysis

BACKGROUND

Livedoid vasculopathy (LV) is a rare cutaneous thrombotic disease. It is characterized by occlusion of dermal vessels resulting in livedo racemosa, ulceration and atrophie blanche. Clear guidelines for diagnosis and treatment are missing.

OBJECTIVE

The purpose of this study was to better characterize epidemiology, clinical appearance and treatment reality of LV in a well-defined patient cohort.

METHODS

The cohort was allocated within a prospective, multicentre, phase IIa trial that investigated the effect of rivaroxaban in LV.

RESULTS

Analysis of 27 patients revealed that LV patients had an increased Body Mass Index (BMI; 11/27), hypertension (19/27) and increased levels of lipoprotein (a) (5/12) and homocysteine (10/12) in the blood. The female-to-male ratio was 2.1 : 1, and the median age was 53.0 years [interquartile range (IQR) 40.5-68]. Investigation of the clinical appearance found that 82% of patients had livedo racemosa, and the ankle region was most likely to be affected by ulceration (56-70%). The analysis of patient treatment history showed that heparin was most effective (12/17), while anti-inflammatory regimens were, although often used (17/24), not effective (0/17).

CONCLUSION

We add clinical clues for a data supported diagnosis of LV, and we provide evidence that anticoagulants should be administered in monotherapy first line (EudraCT number 2012-000108-13-DE).

Livedo vasculopathy: Ablation of the affected vessels to prevent recurrent ulcerations

Background

Livedo vasculopathy is a cutaneous thrombotic microangiopathy favouring the lower legs characterised by an intense reticulate pigmentation, atrophie blanche and recurrent painful stellate ulcerations. There is a strong association with antiphospholipid syndrome, thrombophilic abnormalities, factor V Leiden mutation and more recently, lipoprotein A. Thrombotic occlusion of the dermal venules is the key pathology in livedo vasculopathyand there is no associated vasculitis. Anticoagulation and other currently recommended conservative therapies do not influence the rate of ulcer healing.

Method

Concurrent venous hypertension was treated with endovenous ablative methods. In addition, vessels deemed to be involved in the process of vasculopathy, irrespective of their reflux status were identified on duplex ultrasound or by sight and ablated using endovenous laser and/or sclerotherapy.

Results

Five patients received endovenous intervention while two patients did not undergo any procedures. One patient requested a delay in interventions due to her circumstances and the other patient had multiple contraindications and comorbidities. On long-term follow-up, the intervention achieved complete ulcer healing and resolution of pain without any recurrence in four treated patients.

Conclusion

We recommend ablative venous interventions in suitable patients with livedo vasculopathy to prevent recurrent ulcerations. Compression should be considered as an adjunct treatment.

The management of livedoid vasculopathy focused on direct oral anticoagulants (DOACs): four case reports successfully treated with rivaroxaban

Livedoid vasculopathy (LV) is a thrombotic skin disease characterized by episodic painful ulcerations of the distal aspects of the legs. Its healing process typically leaves small porcelain-white scars called atrophie blanche as a result of the occlusion of cutaneous microcirculation. The main goals of the treatment are pain management and the prevention of ulceration and of progressive scarring in the malleolar area. The therapeutic management is still a challenge, however, and most treatments were based on anecdotal off-label protocols. Over such context, direct oral anticoagulants (DOACS) arise as a potential treatment for this disease. This class of medications became an alternative from initial large studies applied on different pathologic scenarios regarding thromboembolic events. In that line, recent case series using DOACS, including rivaroxaban, started to emerge in the literature related to LV and reported successful prevention of cutaneous infarctions and ulcerations, providing physicians with a new promising alternative. The current report describes four cases of long-term recalcitrant LV, in which rivaroxaban monotherapy effectively reduced pain and cutaneous ulcerations in a few weeks of treatment without relevant side effects. The authors also review therapy management of the disease, focused on DOACS, and suggest a step-by-step approach to treat these patients, taking into consideration different resource profiles of each level of local health centers, the gravity of the cases, and risks/benefits for patients.

MRSA decolonisation using polyhexanide 0.1 % with application where necessary of systemic antibiotics

Background: Increasing infections and drug resistances lead to new treatment concepts in terms of MRSA decolonisation. An antibiotic-free decolonisation treatment with topical antiseptics is of great clinical interest. We investigated the effectiveness of MRSA decolonisation therapy using the topical antiseptic agent polyhexanide 0.1 %. If needed, a systemic antibiotic was added in case of hospitalisation, abscess formation, chronic wounds and others.

Patients and methods: 63 patients were introduced to our outpatient clinic within a period of record of 15 months. 42 (66.7 %) of them were confirmed MRSA-positive and 27 (64.3 %) of these colonised patients were included to the protocol of decolonisation. Patients who followed the protocol of decolonisation (n=27) were investigated in terms of the site of MRSA-colonisation, parameters that minimize the effect of decolonisation, spa types as well as the effectiveness of the topical antiseptic agent polyhexanide 0.1 %.

Results: 22 patients (81.5 %) were successfully decolonised within the group that followed the decolonisation protocol (n=27). Using polyhexanide 0.1 % as single treatment regime seven people (31.8 %) were successfully decolonised, whereas 15 patients (68.2 %) were in need of an additional systemic treatment with antibiotics in order to be decolonised. The implementation of one topical eradication cycle with polyhexanide 0.1 % was effective in case of an exclusive colonisation of the nose (n=3). At maximum, three decolonisation runs were necessary. Within six months of post-eradication investigations no relapses of MRSA were registered.

Conclusions: One third of the decolonised patients were successfully treated with the topical antiseptic polyhexanide 0.1 %, whereas two thirds of the patients that followed the decolonisation protocol were in need of an additional systemic antibiotic.