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Seguí M, Llamas-Velasco M. A comprehensive review on pathogenesis, associations, clinical findings, and treatment of livedoid vasculopathy. Front Med (Lausanne) 2022; 9:993515. [PMID: 36569162 PMCID: PMC9773082 DOI: 10.3389/fmed.2022.993515] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
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.
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Livedoid vasculopathy: A multidisciplinary clinical approach to diagnosis and management. Int J Womens Dermatol 2022; 7:588-599. [PMID: 35024414 PMCID: PMC8721056 DOI: 10.1016/j.ijwd.2021.08.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/15/2021] [Accepted: 08/26/2021] [Indexed: 12/05/2022] Open
Abstract
Livedoid vasculopathy (LV) is a rare, chronic, and occlusive disease of the veins supplying the upper parts of the skin. The pathogenesis of the disease is not precisely understood, and its attacks are often unpredictable but tend to worsen during the summer. LV affects women more often. This increased risk for LV in women might be related to sex-specific physiological conditions, such as pregnancy, or a higher incidence of LV-associated conditions, such as connective tissue diseases, hypercoagulable states, and venous stasis in women. The typical clinical appearance of LV consists of three main findings: livedo racemose, atrophie blanche, and skin ulcers. The purpose of this comprehensive review was to analyze LV in all aspects and mainly focus on early diagnosis for successful clinical management with a holistic and multidisciplinary approach. A detailed history, dermatological examination, and laboratory testing are essential for a diagnosis of LV. When LV is clinically suspected, a skin biopsy should be taken to confirm the diagnosis. Another critical step is to investigate the underlying associated conditions, such as connective tissue diseases, hypercoagulable states, thrombophilia, and malignancy. Unfortunately, no associated conditions can be detected in approximately 20% of all cases (idiopathic LV) despite all efforts. The diagnosis of the disease is delayed in most patients. Thus, irreversible, permanent scars appear. Early and appropriate treatment reduces pain and prevents the development of scars and other complications. Antiplatelet drugs and anticoagulants can be preferred as the first-line treatments along with general supportive measures. Other therapeutic options might be considered in unresponsive cases. Preference for refractory cases is based on availability, clinical experience, and patient-related factors (comorbidities, age, sex, and compliance). These include anabolic steroids, intravenous immunoglobulin, hyperbaric oxygen therapy, psoralen-ultraviolet A, vasodilators, fibrinolytics, immunomodulators, and immunosuppressives.
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Schiffmann ML, Dissemond J, Erfurt-Berge C, Hafner J, Itzlinger-Monshi BA, Jungkunz HW, Kahle B, Kreuter A, Scharffetter-Kochanek K, Lutze S, Rappersberger K, Schneider SW, Strölin A, Sunderkötter C, Goerge T. S1-Leitlinie Diagnostik und Therapie der Livedovaskulopathie. J Dtsch Dermatol Ges 2021; 19:1667-1678. [PMID: 34811901 DOI: 10.1111/ddg.14520_g] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/18/2021] [Indexed: 11/26/2022]
Affiliation(s)
| | | | | | | | | | | | - Birgit Kahle
- Universitätsklinikum Schleswig-Holstein, Campus Lübeck
| | | | | | | | | | | | | | | | - Tobias Goerge
- Klinik für Hautkrankheiten, Universitätsklinik Münster
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Schiffmann ML, Dissemond J, Erfurt-Berge C, Hafner J, Itzlinger-Monshi BA, Jungkunz HW, Kahle B, Kreuter A, Scharffetter-Kochanek K, Lutze S, Rappersberger K, Schneider SW, Strölin A, Sunderkötter C, Goerge T. German S1 guideline: diagnosis and treatment of livedovasculopathy. J Dtsch Dermatol Ges 2021; 19:1668-1678. [PMID: 34739187 DOI: 10.1111/ddg.14520] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | | | | | | | - Birgit Kahle
- University Hospital Schleswig-Holstein, Campus Lübeck
| | | | | | | | | | | | | | | | - Tobias Goerge
- Department of Skin Diseases, University Hospital Münster
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Atrophie blanche: is it associated with venous disease or livedoid vasculopathy? Adv Skin Wound Care 2016; 27:518-24; quiz 525-6. [PMID: 25325229 DOI: 10.1097/01.asw.0000455098.98684.95] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this learning activity is to provide information about the etiology and treatment of atrophie blanche. TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES After participating in this educational activity, the participant should be better able to:1. Discuss the pathophysiology of atrophie blanche.2. Explore treatment options for livedoid vasculopathy. ABSTRACT Atrophie blanche (AB) is a porcelain-white scar that may be seen at the base of a healed ulcer or in association with livedoid vasculopathy (LV). The term AB originally had been used synonymously with LV, whereas LV is a noninflammatory thrombotic condition presenting as either a primary or secondary event (often associated with coagulation).
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Abstract
Leg ulcers are a common health problem. Ulcers of any etiology including venous ulcers may be very painful, but until recently, health professionals have not been good at recognizing or managing this type of pain. It is important to clarify the type, severity, and frequency of pain and to anticipate pain at dressing changes. The measurement of pain by the use of pain scales is very useful, particularly in assessing the efficacy of an intervention. Neuropathic pain and unusually painful ulcerations are discussed in this article.
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Affiliation(s)
- Susan M Cooper
- Department of Dermatology, Churchill Hospital, Oxford, UK.
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Monshi B, Posch C, Vujic I, Sesti A, Sobotka S, Rappersberger K. Efficacy of intravenous immunoglobulins in livedoid vasculopathy: Long-term follow-up of 11 patients. J Am Acad Dermatol 2014; 71:738-44. [DOI: 10.1016/j.jaad.2014.05.039] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 05/13/2014] [Accepted: 05/15/2014] [Indexed: 10/25/2022]
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Alavi A, Hafner J, Dutz JP, Mayer D, Sibbald RG, Criado PR, Senet P, Callen JP, Phillips TJ, Romanelli M, Kirsner RS. Livedoid vasculopathy: An in-depth analysis using a modified Delphi approach. J Am Acad Dermatol 2013; 69:1033-1042.e1. [DOI: 10.1016/j.jaad.2013.07.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 07/16/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
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Tubone MQ, Escobar GF, Peruzzo J, Schestatsky P, Maldonado G. Livedoid vasculopathy associated with peripheral neuropathy: a report of two cases. An Bras Dermatol 2013; 88:227-9. [PMID: 24346927 PMCID: PMC3876016 DOI: 10.1590/abd1806-4841.20132363] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 05/15/2013] [Indexed: 11/22/2022] Open
Abstract
Livedoid vasculopathy (LV) is a chronic and recurrent disease consisting of livedo reticularis and symmetric ulcerations, primarily located on the lower extremities, which heal slowly and leave an atrophic white scar ("atrophie blanche"). Neurological involvment is rare and presumed to be secondary to the ischemia from vascular thrombosis of the vasa nervorum. Laboratory evaluation is needed to exclude secondary causes such as hyper-coagulable states, autoimmune disorders and neoplasms. We present two patients with a rare association of peripheral neuropathy and LV, thereby highlighting the importance of a multidisciplinary approach to reach the correct diagnosis.
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Affiliation(s)
- Mariana Quirino Tubone
- Medical Resident at the Dermatology Service of the Hospital de Clínicas
de Porto Alegre - Federal University of Rio Grande do Sul (HCPA - UFRGS) - Porto Alegre
(RS), Brazil
| | - Gabriela Fortes Escobar
- Medical Resident at the Dermatology Service of the Hospital de Clínicas
de Porto Alegre - Federal University of Rio Grande do Sul (HCPA - UFRGS) - Porto Alegre
(RS), Brazil
| | - Juliano Peruzzo
- Medical Resident at the Dermatology Service of the Hospital de Clínicas
de Porto Alegre - Federal University of Rio Grande do Sul (HCPA - UFRGS) - Porto Alegre
(RS), Brazil
| | - Pedro Schestatsky
- PhD from the Federal University of Rio Grande do Sul (UFRGS) - Adjunct
Professor of Internal Medicine, Federal University of Rio Grande do Sul (UFRGS) - Porto
Alegre (RS), Brazil
| | - Gabriela Maldonado
- MSc in Medical Sciences - Dermatology from the Federal University of
Rio Grande do Sul - Preceptor at Dermatology Service of the Hospital de Clínicas de
Porto Alegre - Federal University of Rio Grande do Sul (HCPA - UFRGS) - Porto Alegre
(RS), Brazil
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Criado PR, Rivitti EA, Sotto MN, Valente NYS, Aoki V, Carvalho JFD, Vasconcellos C. Livedoid vasculopathy: an intringuing cutaneous disease. An Bras Dermatol 2012; 86:961-77. [PMID: 22147037 DOI: 10.1590/s0365-05962011000500015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 12/27/2010] [Indexed: 11/21/2022] Open
Abstract
Livedoid vasculopathy is a skin disease that occludes the blood vessels of the dermis. It has a pauciinflammatory or non-inflammatory nature. It is characterized by the presence of macular or papular, erythematous-purpuric lesions affecting the legs, especially the ankles and feet, and producing intensely painful ulcerations, which cause white atrophic scars called "atrophie blanche". This review includes studies and case reports found in the medical literature regarding the etiopathogenic associations of the disease, particularly those related to thrombophilia, their histopathological findings and the therapeutic approaches used in the difficult clinical management of these cases.
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Affiliation(s)
- Paulo Ricardo Criado
- Divisão de Dermatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brasil.
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Gan EY, Tang MBY, Tan SH, Chua SH, Tan AWH. A Ten-Year Retrospective Study on Livedo Vasculopathy in Asian Patients. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2012. [DOI: 10.47102/annals-acadmedsg.v41n9p400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: This study aims to analyse the clinico-epidemiological characteristics of Asian patients diagnosed with livedo vasculopathy (LV). Materials and Methods: We performed a retrospective analysis of all patients diagnosed with LV from 1997 to 2007 at our centre. Results: Seventy patients were diagnosed with LV with a mean age of 39 years, female: male ratio of 3:1 and no racial predilection. Most cases remained purely cutaneous, presenting with painful leg ulcers and atrophie blanche. Peripheral neuropathy was the only extra-cutaneous complication (9%). In patients who were screened, associations included hepatitis B (7%) and hepatitis C (4%), positive anti-nuclear antibody (14%), positive anti-myeloperoxidase antibody (5%), positive anti-cardiolipin antibodies (7%) and positive lupus anticoagulant (2%). In 49 patients who achieved remission, 55% required combination therapy, most commonly with colchicine, pentoxifylline and prednisolone. In those treated successfully with monotherapy, colchicine was effective in 59% followed by prednisolone (17.5%), pentoxifylline (17.5%) and aspirin (6%). Mean follow-up period was 50 months. Conclusion: LV in Asian patients is a high morbidity, chronic relapsing ulcerative skin condition. Most patients require induction combination therapy for remission. As further evidence emerges to support a procoagulant pathogenesis, a standardised protocol is needed to investigate for prothrombotic disorders during diagnosis.
Key words: Atrophie blanche, Livedo reticularis, Livedoid vasculitis
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Gonzalez-Santiago TM, Davis MDP. Update of management of connective tissue diseases: livedoid vasculopathy. Dermatol Ther 2012; 25:183-94. [DOI: 10.1111/j.1529-8019.2012.01490.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Criado PR, Rivitti EA, Sotto MN, de Carvalho JF. Livedoid vasculopathy as a coagulation disorder. Autoimmun Rev 2011; 10:353-60. [DOI: 10.1016/j.autrev.2010.11.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 11/16/2010] [Indexed: 10/18/2022]
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Davis MD, Wysokinski WE. Ulcerations caused by livedoid vasculopathy associated with a prothrombotic state: Response to warfarin. J Am Acad Dermatol 2008; 58:512-5. [DOI: 10.1016/j.jaad.2006.04.087] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Revised: 03/22/2006] [Accepted: 04/04/2006] [Indexed: 10/22/2022]
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Abstract
Fototerapia é utilizada para tratar uma grande variedade de dermatoses. Desde o século passado a fototerapia tem sido utilizada em várias modalidades, com irradiação UVA ou UVB. Está indicada para todos os tipo de dermatoses inflamatórias e com período crônico de evolução, como vitiligo, pasoríase, parapsoríase, linfomas cutâneos de células T, eczemas crônicos, demonstrando bons resultados terapêuticos. Pode ser utilizada como monoterapia ou associada a outras drogas, como retinóides, metotrexate, ciclosporina, com objetivo de diminuir o tempo de tratamento e as doses das medicações mencionadas. Como os demais tipos de tratamento, a fototerapia apresenta algumas limitações, como a necessidade de equipamentos específicos, a adesão do paciente, a possibilidade de indicação ao paciente e a dose cumulativa de irradiação UV. A fototerapia deve ser conduzida com seguimento criterioso para a obtenção de resposta efetiva com poucos efeitos colaterais.
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Affiliation(s)
- Ida Duarte
- Santa Casa de São Paulo; Santa Casa de Misericórdia de São Paulo, Brasil
| | - Roberta Buense
- Santa Casa de Misericórdia de São Paulo, Brasil; Universidade de São Paulo
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Juan WH, Chan YS, Lee JC, Yang LC, Hong HS, Yang CH. Livedoid vasculopathy: long-term follow-up results following hyperbaric oxygen therapy. Br J Dermatol 2005; 154:251-5. [PMID: 16433793 DOI: 10.1111/j.1365-2133.2005.06843.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Livedoid vasculopathy, also known as atrophie blanche, is a recurrent painful vasculopathy appearing mostly on the lower limbs. Treatment is challenging and relapses are frequent. OBJECTIVES To analyse the long-term effect and safety of hyperbaric oxygen (HBO) therapy in treating livedoid vasculopathy. METHODS Twelve patients with active livedoid vasculopathy were included in this study. All patients underwent HBO therapy five times a week. Each week photographs were taken and the total dose of analgesics was recorded. Side-effects were documented and assessed. Recurrence was defined as the presence of skin ulceration. RESULTS Of the eight patients who completed the treatment, resumption of ambulation and reduction of analgesics were achieved at an average of 4.9 HBO therapy sessions. Leg ulcers in all eight patients healed completely at a mean of 3.4 weeks (range 2-5 weeks). Six patients suffered relapses of ulceration and responded to additional HBO therapy. No significant side-effects were found. CONCLUSIONS HBO is a relatively safe, fast and effective method to treat patients with livedoid vasculopathy.
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Affiliation(s)
- W-H Juan
- Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan
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Tuchinda C, Leenutaphong V, Sudtim S, Lim HW. Refractory livedoid vasculitis responding to PUVA: a report of four cases. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2005; 21:154-6. [PMID: 15888134 DOI: 10.1111/j.1600-0781.2005.00151.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Livedoid vasculitis is a chronic disease characterized by recurrent painful irregularly shaped ulcers, which heal with scars, most commonly located on feet or lower extremities. This condition is often resistant to the therapy. We report four cases with refractory livedoid vasculitis that responded to systemic psoralens and ultraviolet A radiation therapy.
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Affiliation(s)
- C Tuchinda
- Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand.
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Toth C, Trotter M, Clark A, Zochodne D. Mononeuropathy multiplex in association with livedoid vasculitis. Muscle Nerve 2003; 28:634-9. [PMID: 14571469 DOI: 10.1002/mus.10450] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Livedoid vasculitis is a chronic dermatological disorder associated with petechiae and recurrent, unusually shaped ulcers that heal to form hyperpigmentated areas and atrophie blanche. This condition is more correctly termed a vasculopathy, rather than a vascultis, and is often associated with an underlying hypercoagulable disorder. We report a patient with livedoid vasculitis and mononeuropathy multiplex. We propose that peripheral nervous system involvement arises from multifocal areas of ischemia due to fibrin and thrombin deposition within both the wall and lumen of vasa nervorum.
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Affiliation(s)
- Cory Toth
- Department of Neurological Sciences, Room 165, Heritage Medical Research Building, University of Calgary, 3330 Hospital Dr. NW, Calgary, Alberta T2N 4N1, Canada.
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Yang CH, Ho HC, Chan YS, Liou LB, Hong HS, Yang LC. Intractable livedoid vasculopathy successfully treated with hyperbaric oxygen. Br J Dermatol 2003; 149:647-52. [PMID: 14511004 DOI: 10.1046/j.1365-2133.2003.05546.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe a new method for treating livedoid vasculopathy. The typical presentation of livedoid vasculopathy includes chronic, recurrent painful ulcers, satellite scar-like atrophy and telangiectasia involving the lower extremities. Histologically, these lesions show areas of ulceration and dermal vessel occlusion without frank inflammatory cell infiltration. There is currently no satisfactory therapy available for this disease. Hyperbaric oxygen (HBO) has recently established itself as one of the most effective methods of treating ischaemic wounds, including diabetic ulcers. We used this therapy in two patients whose lesions were resistant to multiple therapeutic modalities. Not only did their ulcers respond rapidly to the HBO therapy, but the disturbing wound pain also resolved at the same time. To our knowledge, this is the first successful trial of HBO therapy in livedoid vasculopathy. We believe this to be a very promising new therapy for livedoid vasculopathy and to be worth further investigation.
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Affiliation(s)
- C-H Yang
- Department of Dermatology, Chang Gung Memorial Hospital, 199 Tun Hwa North Road, Taipei, Taiwan
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Affiliation(s)
- Andreas Katsambas
- University of Athens, Department of Dermatology, A Sygros Hospital, Athens, Greece.
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