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Zhang L, Ng K, Pham JP, Thoo S, Yang A, Kang M, Connor D, Kossard S, Parsi K. Pigmentation of lower limbs: Contribution of haemosiderin and melanin in chronic venous insufficiency and related disorders. Phlebology 2023; 38:657-667. [PMID: 37642293 DOI: 10.1177/02683555231196702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND To determine the composition of skin pigmentation in chronic venous insufficiency (CVI) and other less common vascular conditions of lower limbs. METHODS Forty-five skin biopsies were obtained from 17 patients. Samples were taken from pigmented regions and compared with control non-lesional samples from the same patient. Perl's Prussian Blue was used to identify haemosiderin and Schmorl's for melanin. RESULTS Seven patients presented with CVI, one with concurrent livedo vasculopathy (LV). One patient had LV only. Two patients had acroangiodermatitis (AAD). Six patients had post-sclerotherapy pigmentation (PSP), one with concurrent post-inflammatory hyperpigmentation (PIH). One patient had PIH only. The predominant pigment in CVI samples was haemosiderin. C5-C6 patients showed increased epidermal melanin. LV, AAD, and PSP samples showed dermal haemosiderin but no increase in epidermal melanin. PIH samples showed prominent epidermal melanin whilst no haemosiderin was detected. CONCLUSION The predominant pigment in CVI and other vascular conditions was haemosiderin. Melanin was present in later stages of CVI (C5-C6) and in PIH.
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Affiliation(s)
- Lois Zhang
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Dermatology, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Kate Ng
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Faculty of Medicine, The University of New South Wales(UNSW), Sydney, NSW, Australia
| | - James P Pham
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Dermatology, St. Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine, The University of New South Wales(UNSW), Sydney, NSW, Australia
| | - Samuel Thoo
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Dermatology, St. Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine, The University of New South Wales(UNSW), Sydney, NSW, Australia
| | - Anes Yang
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Dermatology, St. Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine, The University of New South Wales(UNSW), Sydney, NSW, Australia
| | - Mina Kang
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Dermatology, St. Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine, The University of New South Wales(UNSW), Sydney, NSW, Australia
| | - David Connor
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Faculty of Medicine, The University of New South Wales(UNSW), Sydney, NSW, Australia
| | - Steven Kossard
- Faculty of Medicine, The University of New South Wales(UNSW), Sydney, NSW, Australia
- Kossard Dermatopathologists, Sydney, NSW, Australia
| | - Kurosh Parsi
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Dermatology, St. Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine, The University of New South Wales(UNSW), Sydney, NSW, Australia
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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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Eswaran H, Googe P, Vedak P, Marston WA, Moll S. Livedoid vasculopathy: A review with focus on terminology and pathogenesis. Vasc Med 2022; 27:593-603. [PMID: 36285834 PMCID: PMC9732787 DOI: 10.1177/1358863x221130380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Harish Eswaran
- Department of Medicine, Division of
Hematology, University of North Carolina School of Medicine, Chapel Hill, NC,
USA
| | - Paul Googe
- Department of Dermatology, University
of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Priyanka Vedak
- Department of Dermatology, University
of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - William A Marston
- Department of Surgery, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Stephan Moll
- Department of Medicine, Division of
Hematology, University of North Carolina School of Medicine, Chapel Hill, NC,
USA
- Blood Research Center, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
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Burg MR, Mitschang C, Goerge T, Schneider SW. Livedoid vasculopathy - A diagnostic and therapeutic challenge. Front Med (Lausanne) 2022; 9:1012178. [PMID: 36262273 PMCID: PMC9574051 DOI: 10.3389/fmed.2022.1012178] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/15/2022] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Maria Rosa Burg
- Department of Dermatology and Venereology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Carolin Mitschang
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
| | - Tobias Goerge
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany,*Correspondence: Tobias Goerge,
| | - Stefan Werner Schneider
- Department of Dermatology and Venereology, University Medical Center Hamburg Eppendorf, Hamburg, Germany,Stefan Werner Schneider,
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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: 5] [Impact Index Per Article: 2.5] [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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6
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Kawabe R, Tonomura K, Kotobuki Y, Ueda-Hayakawa I, Murota H, Fujimoto M. Exacerbation of livedoid vasculopathy after coronavirus disease 2019. Eur J Dermatol 2022; 32:129-131. [PMID: 35653093 PMCID: PMC9170554 DOI: 10.1684/ejd.2022.4200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ryoko Kawabe
- Department of Dermatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Kyoko Tonomura
- Department of Dermatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Yorihisa Kotobuki
- Department of Dermatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Ikuko Ueda-Hayakawa
- Department of Dermatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Hiroyuki Murota
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
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Forbes J, Heydari M, Kesselman MM, Villacorta M. Recognition and Management of Cutaneous Polyarteritis Nodosum Versus Livedoid Vasculitis: A Case Report. Cureus 2020; 12:e6788. [PMID: 32140348 PMCID: PMC7045993 DOI: 10.7759/cureus.6788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Cutaneous polyarteritis nodosum (CPAN) is a vasculitis of small and medium-sized muscular arteries of the dermis and subcutaneous tissue with no associated systemic involvement. A common presentation of CPAN can be misinterpreted as a non-invasive form of livedoid vasculitis, synonymous with the “atrophie blanche” which similarly presents as ivory-white stellate-shaped scars. Although hyperpigmentation can also be present, as seen in our 47-year-old female patient, cutaneous polyarteritis nodosum is unique due to the etiology of the inflammatory illness which requires a deep, segmented skin biopsy for diagnosis in order to identify the vessel inflammation. In this case report, we discuss a patient with a 20-year history of painful, recurrent ulcerations and polyneuritis with previous ulcer eruptions that healed as ivory-white stellate scarring. AB cutaneous forms of polyarteritis nodosum (PAN) may be only one manifestation of the disease, with other presentations in association with multi-organ system disease. This report will discuss the necessity of a high index of clinical suspicion with a clinical presentation similar to that of our patient. We will discuss the importance of early recognition and diagnosis of cutaneous vasculitis, such as CPAN, based on clinical presentation and history in hopes of limiting morbidity and the risk of progression to systemic forms of the disease.
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Affiliation(s)
- Jessica Forbes
- Dermatology, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, USA
| | - Milad Heydari
- Dermatology, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, USA
| | - Marc M Kesselman
- Rheumatology, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, USA
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Grinnell M, Bath A, DiMaio D, Hultgren T, Hearth-Holmes M. Retiform non-blanchable purpuric plaques in a patient with systemic lupus erythematosus. Lupus 2019; 28:1013-1016. [PMID: 31126212 DOI: 10.1177/0961203319847274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Livedoid vasculopathy (LV) is a small vessel occlusive disease that can present with a painful purpuric eruption. Predominantly affecting young women, LV has been associated with hypercoagulable states and antiphospholipid syndrome. We present an unusual case of LV occurring in the setting of acute kidney injury secondary to lupus nephritis. It is important to differentiate LV from vasculitis as the treatment recommendation centers on anticoagulation therapy rather than immunosuppression. Additionally, antiphospholipid syndrome should be ruled out in cases of systemic lupus erythematosus with LV due to risk of thrombotic events.
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Affiliation(s)
- M Grinnell
- 1 College of Medicine, University of Nebraska Medical Center, Omaha, USA
| | - A Bath
- 2 Department of Rheumatology, University of Nebraska Medical Center, Omaha, USA
| | - D DiMaio
- 3 Department of Pathology, University of Nebraska Medical Center, Omaha, USA
| | - T Hultgren
- 4 Dermatology Specialists of Omaha, Omaha, USA
| | - M Hearth-Holmes
- 2 Department of Rheumatology, University of Nebraska Medical Center, Omaha, USA
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9
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Wollina U. Dermoscopy of early non-ulcerated livedoid vasculopathy. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2018. [DOI: 10.15570/actaapa.2018.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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