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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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Ramphall S, Rijal S, Prakash V, Ekladios H, Mulayamkuzhiyil Saju J, Mandal N, Kham NI, Shahid R, Naik SS, Venugopal S. Comparative Efficacy of Rivaroxaban and Immunoglobulin Therapy in the Treatment of Livedoid Vasculopathy: A Systematic Review. Cureus 2022; 14:e28485. [PMID: 36051980 PMCID: PMC9420174 DOI: 10.7759/cureus.28485] [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] [Received: 07/16/2022] [Accepted: 08/27/2022] [Indexed: 11/17/2022] Open
Abstract
Livedoid vasculopathy (LV) is an uncommon chronic coagulation disorder whose underlying etiology is not yet fully understood. It predominantly affects females, especially those in late adolescence. There is currently limited research on treatment options for those with this diagnosis. The present systematic review aims to compare the efficacy of rivaroxaban and intravenous immunoglobulin (IVIG) therapy in the treatment of livedoid vasculopathy. A detailed search was conducted from April 20, 2022, to May 1, 2022, using four databases: Elsevier, Medline Complete, Medline Ovid, and PubMed. Out of these, 20 relevant articles were used, and the data was extracted and analyzed. Both rivaroxaban and IVIG were shown to be effective treatment options with similar treatment response times. However, future large-scale clinical trials are needed to determine an established treatment regimen for these patients.
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Affiliation(s)
- Shivana Ramphall
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Swarnima Rijal
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Vishakh Prakash
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Heba Ekladios
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Naishal Mandal
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nang I Kham
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rabia Shahid
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shaili S Naik
- Internal medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sathish Venugopal
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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3
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Gao Y, Jin H. Efficacy and safety of intravenous immunoglobulin for treating refractory livedoid vasculopathy: a systematic review. Ther Adv Chronic Dis 2022; 13:20406223221097331. [PMID: 35634570 PMCID: PMC9134453 DOI: 10.1177/20406223221097331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/12/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Yimeng Gao
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Hongzhong Jin
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, No.1 Shuaifuyuan, Dongcheng district, Beijing, 100730 China
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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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Takahagi S, Tanaka M, Morioke S, Suehiro M, Tanaka A, Hide M. Long‐term remission of severe livedoid vasculopathy treated with a short course of intravenous immunoglobulin. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2021. [DOI: 10.1002/cia2.12202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Shunsuke Takahagi
- Department of Dermatology Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
| | - Maiko Tanaka
- Department of Dermatology Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
| | - Satoshi Morioke
- Department of Dermatology Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
| | - Masataka Suehiro
- Department of Dermatology Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
| | - Akio Tanaka
- Department of Dermatology Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
| | - Michihiro Hide
- Department of Dermatology Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
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Kofler K, Strölin A, Geiger V, Kofler L. Intravenous Immunoglobulin Therapy in Livedoid Vasculopathy: Retrospective Observation of Clinical Outcome and Patient's Activity Level. J Cutan Med Surg 2021; 25:504-510. [PMID: 33779349 PMCID: PMC8474298 DOI: 10.1177/12034754211003525] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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).
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Affiliation(s)
- Katrin Kofler
- 9188 Department of Dermatology, Eberhard-Karls University, Tübingen, Germany
| | - Anke Strölin
- 9188 Department of Dermatology, Eberhard-Karls University, Tübingen, Germany
| | - Vanessa Geiger
- 9188 Department of Dermatology, Eberhard-Karls University, Tübingen, Germany
| | - Lukas Kofler
- 9188 Department of Dermatology, Eberhard-Karls University, Tübingen, Germany
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Yoshioka K, Tateishi C, Kato H, Chen K. Systemic lupus erythematosus with refractory ulcerated livedoid vasculopathy: Successful treatment with intravenous immunoglobulin and warfarin. Clin Case Rep 2018; 6:2045-2047. [PMID: 30455888 PMCID: PMC6230605 DOI: 10.1002/ccr3.1803] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/27/2018] [Accepted: 08/15/2018] [Indexed: 11/12/2022] Open
Abstract
We reported a patient with systemic lupus erythematosus complicated by livedoid vasculopathy (LV), who responded well to intravenous immunoglobulin and warfarin. Cutaneous lesions of LV resemble those of cutaneous vasculitis. LV should be included in the differential diagnosis of leg ulcerations even in the presence of autoimmune disorders.
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Affiliation(s)
- Katsunobu Yoshioka
- Department of Internal MedicineSocial Welfare Foundation Shitennoji HospitalOsakaJapan
| | - Chiharu Tateishi
- Department of DermatologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Hiromi Kato
- Department of NursingSocial Welfare Foundation Shitennoji HospitalOsakaJapan
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9
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Affiliation(s)
- Elaine Kunzler
- University of Texas Southwestern Medical Center, Dallas, Texas.,Northeast Ohio Medical University, Rootstown, Ohio
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10
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Navarro-Triviño F, Pérez-López I, Ruíz-Villaverde R. Dermatology and Immunoglobulin Therapy: Who to Treat and How to Administer Immunoglobulins. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Navarro-Triviño FJ, Pérez-López I, Ruíz-Villaverde R. Dermatology and Immunoglobulin Therapy: Who to Treat and How to Administer Immunoglobulins. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:323-330. [PMID: 29429551 DOI: 10.1016/j.ad.2017.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 10/16/2017] [Accepted: 11/05/2017] [Indexed: 12/23/2022] Open
Abstract
Intravenous immunoglobulin (IVIG) replacement therapy has been used in immune deficiency diseases for more than 50 years. The indications for this treatment have evolved, however, and IVIG therapy is now used in various diseases in which the immune system plays a prominent role. IVIG therapy has carved out a niche in dermatology for the treatment of such conditions as dermatomyositis, autoimmune bullous diseases, and toxic epidermal necrolysis. Special attention has been paid to this therapy in recent years. New guidelines have been published and should be taken into consideration in dermatology. This review provides a practical guide to IVIG use in our specialty.
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Affiliation(s)
- F J Navarro-Triviño
- Unidad de Dermatología Médico-Quirúrgica y Venereología, Hospital Comarcal Santa Ana, Motril, España.
| | - I Pérez-López
- Unidad de Gestión Clínica de Dermatología y Venereología, Complejo Hospitalario Universitario de Granada, Granada, España
| | - R Ruíz-Villaverde
- Unidad de Gestión Clínica de Dermatología y Venereología, Complejo Hospitalario Universitario de Granada, Granada, España
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12
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Volc S, Maier JC, Röcken M. [Skin diseases due to systemic vasculitides and vasculopathies]. Hautarzt 2017; 67:948-959. [PMID: 27864582 DOI: 10.1007/s00105-016-3896-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vasculitis and vasculopathy are two distinct disease entities. Each entity comprises a large number of heterogeneous diseases, which can occur alone or associated with autoimmune, infectious or neoplastic diseases. The terms vasculitis and vasculopathy are often falsely used synonymously. A vasculitis initially causes inflammation of the vessel walls that may result in a secondary occlusion. In contrast, a vasculopathy is a primary occlusion of the vascular lumen, which is followed by inflammation after ischemia and ulceration. In most patients the distinction can be made based on the clinical presentation. A clear clinical diagnosis is then followed by targeted serological, histological and imaging procedures to confirm the clinical diagnosis. On this basis a well-founded treatment can be initiated. In the presence of vasculitis an anti-inflammatory therapy is indicated, whereas in the case of vasculopathy, removal of the vascular occlusion is the main focus. This article provides an overview of the various diseases and addresses the pathogenetic and clinical characteristics used to differentiate the individual disease entities. It also provides an insight into the therapy options and prophylaxis.
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Affiliation(s)
- S Volc
- Universitäts-Hautklinik Tübingen, Liebermeisterstr. 25, 72076, Tübingen, Deutschland
| | - J C Maier
- Universitäts-Hautklinik Tübingen, Liebermeisterstr. 25, 72076, Tübingen, Deutschland
| | - M Röcken
- Universitäts-Hautklinik Tübingen, Liebermeisterstr. 25, 72076, Tübingen, Deutschland.
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14
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Kim EJ, Yoon SY, Park HS, Yoon HS, Cho S. Pulsed intravenous immunoglobulin therapy in refractory ulcerated livedoid vasculopathy: seven cases and a literature review. Dermatol Ther 2015; 28:287-90. [DOI: 10.1111/dth.12233] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Eun Jee Kim
- Department of Dermatology; Seoul National University Boramae Hospital; Seoul Korea
| | | | - Hyun Sun Park
- Department of Dermatology; Seoul National University Boramae Hospital; Seoul Korea
| | - Hyun-Sun Yoon
- Department of Dermatology; Seoul National University Boramae Hospital; Seoul Korea
| | - Soyun Cho
- Department of Dermatology; Seoul National University Boramae Hospital; Seoul Korea
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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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