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Hofmann AG, Deinsberger J, Oszwald A, Weber B. The Histopathology of Leg Ulcers. Dermatopathology (Basel) 2024; 11:62-78. [PMID: 38390849 PMCID: PMC10885126 DOI: 10.3390/dermatopathology11010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.
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Affiliation(s)
- Amun Georg Hofmann
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - André Oszwald
- Department of Pathology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Benedikt Weber
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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2
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Bhatt DM, Bhamburkar S, Madke B, Jangid SD, Khan A. Adalimumab in the Treatment of Recalcitrant Livedoid Vasculopathy. Cureus 2023; 15:e50053. [PMID: 38186477 PMCID: PMC10768940 DOI: 10.7759/cureus.50053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Livedoid vasculopathy is a rare condition affecting the cutaneous vasculature. Patients typically develop bilateral lower limb ulcers that tend to recur and do not heal. Edema, discomfort, and itching are linked to ulcers. The patient's quality of life is negatively impacted by this. Atrophie blanche, a stellate, porcelain-white scar, is typically left behind once these ulcers heal. Livedoid vasculitis, livedo reticularis with ulcerations, atrophie blanche, segmental hyalinizing vasculitis, and painful purpuric ulcers with a reticular pattern on the lower limbs are some of the terminologies used to describe livedoid vasculopathy. This condition has been treated using various techniques, including intravenous immunoglobulins, steroids, anticoagulants, antibiotics, immunosuppressive drugs, and antiplatelets. Here, we report the case of a 24-year-old male who presented with a red-colored, painful, and itchy lesion over his right calf for one year. He had recurring lesions over his right foot for the past 18 years. He had received multiple treatment courses over 18 years but had no relief. He was treated with eight doses of adalimumab injection (40 mg/0.8 mL) administered subcutaneously at an interval of 15 days. He had near-complete healing of the ulcer and complete remission of symptoms.
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Affiliation(s)
- Drishti M Bhatt
- Dermatology, Venereology and Leprosy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sangeeta Bhamburkar
- Dermatology, Venereology and Leprosy, Bhamburkar Hospital and Skin Clinic, Akola, IND
| | - Bhushan Madke
- Dermatology, Venereology and Leprosy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shivani D Jangid
- Dermatology, Venereology and Leprosy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Arshiya Khan
- Dermatology, Venereology and Leprosy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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3
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Hallak A, Bennett W, Tanbir MA, Donthamsetty SR, Vincent B. Penile Livedoid Vasculopathy: First Reported Case. Case Rep Vasc Med 2023; 2023:6920383. [PMID: 37440957 PMCID: PMC10335878 DOI: 10.1155/2023/6920383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 04/11/2023] [Accepted: 06/09/2023] [Indexed: 07/15/2023] Open
Abstract
Livedoid vasculopathy is a thromboocclusive cutaneous vasculopathy manifested by livedoid changes, atrophie blanche, and ulceration. The pathogenesis is speculated to involve increasing coagulation or impaired thrombolysis leading to the occlusion of dermal blood vessels with fibrin thrombi. Livedoid vasculopathy is known to primarily affect the lower extremities. We report the first case of livedoid vasculopathy affecting the penis. A 60-year-old male was evaluated for a split urine stream with associated irritation and peeling of the skin of the glans penis. His penile ulcer continued to enlarge despite steroids and antibiotics. Due to diagnostic uncertainty, a biopsy was performed which revealed hyaline thrombi within the lumens of small vessels within the upper to mid dermis, fibrinoid material in the walls of these blood vessels and within the perivascular stroma with overlying and adjacent epidermal spongiosis, and mild perivascular lymphocytic infiltrate with a few scattered neutrophils most consistent with livedoid vasculitis. He was started on aspirin and pentoxifylline with limited improvement and was later started on apixaban with near-complete resolution in 6 months. Penile livedoid vasculopathy has not been previously reported in the English literature. Early diagnosis and treatment are imperative to limit morbidity.
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Affiliation(s)
- Ahmad Hallak
- Ochsner Medical Center, New Orleans, Louisiana, USA
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4
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Drummond MR, Santos LSD, Souza LB, Mitsuushi GN, Cintra ML, França AFEDC, Souza EMD, Velho PENF. Detection of Bartonella henselae DNA in the blood of patients with livedoid vasculopathy. An Bras Dermatol 2023:S0365-0596(23)00066-1. [PMID: 36973097 DOI: 10.1016/j.abd.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Livedoid vasculopathy (LV) manifests as ulcers and atrophic white scars on the lower extremities. The main known etiopathogenesis is hypercoagulability with thrombus formation, followed by inflammation. Thrombophilia, collagen and myeloproliferative diseases may induce LV, but the idiopathic (primary) form predominates. Bartonella sp. may cause intra-endothelial infection and skin manifestations caused by these bacteria may be diverse, including leukocytoclastic vasculitis and ulcers. OBJECTIVE The aim of this study was to investigate the presence of bacteremia by Bartonella spp. in patients with difficult-to-control chronic ulcers diagnosed as primary LV. METHODS Questionnaires and molecular tests (conventional PCR, nested PCR and real-time PCR) were applied and liquid and solid cultures were performed in the blood samples and blood clot of 16 LV patients and 32 healthy volunteers. RESULTS Bartonella henselae DNA was detected in 25% of LV patients and in 12.5% of control subjects but failed to reach statistically significant differences (p = 0.413). STUDY LIMITATIONS Due to the rarity of primary LV, the number of patients studied was small and there was greater exposure of the control group to risk factors for Bartonella spp. INFECTION CONCLUSION Although there was no statistically significant difference between the groups, the DNA of B. henselae was detected in one of every four patients, which reinforces the need to investigate Bartonella spp. in patients with primary LV.
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Affiliation(s)
- Marina Rovani Drummond
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil; Laboratory of Applied Research in Dermatology and Bartonella Infection, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil.
| | - Luciene Silva Dos Santos
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil; Laboratory of Applied Research in Dermatology and Bartonella Infection, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
| | - Lais Bomediano Souza
- Department of Medicine, Pontifícia Universidade Católica de Campinas, Campinas, São Paulo, SP, Brazil
| | - Gabriela Nero Mitsuushi
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
| | - Maria Letícia Cintra
- Department of Pathological Anatomy, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
| | | | - Elemir Macedo de Souza
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
| | - Paulo Eduardo Neves Ferreira Velho
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil; Laboratory of Applied Research in Dermatology and Bartonella Infection, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
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5
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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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6
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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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7
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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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8
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9
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Valentim FDO, Tsutsui GM, Miot HA. Recrudescence of livedoid vasculopathy induced by COVID-19. Int J Dermatol 2021; 60:e185-e187. [PMID: 33527356 PMCID: PMC8013770 DOI: 10.1111/ijd.15423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/08/2020] [Accepted: 01/04/2021] [Indexed: 12/12/2022]
Affiliation(s)
| | | | - Hélio Amante Miot
- Departamento de Dermatologia e Radioterapia, FMB-UNESP, Botucatu, Brazil
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10
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Mitri F, Enk A, Bersano A, Kraemer M. Livedo racemosa in neurological diseases: an update on the differential diagnoses. Eur J Neurol 2020; 27:1832-1843. [DOI: 10.1111/ene.14390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 11/29/2022]
Affiliation(s)
- F. Mitri
- Department of Dermatology University Hospital Heidelberg Heidelberg Germany
| | - A. Enk
- Department of Dermatology University Hospital Heidelberg Heidelberg Germany
| | - A. Bersano
- Cerebrovascular Unit Fondazione IRCCS Istituto Neurologico ‘Carlo Besta’ Milan Italy
| | - M. Kraemer
- Department of Neurology Alfried Krupp von Bohlen und Halbach Hospital Essen Germany
- Department of Neurology Heinrich Heine University Hospital Düsseldorf Germany
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11
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He H, Wu N. A 75-year-old woman with primary antiphospholipid syndrome presenting with livedoid vasculopathy. Dermatol Ther 2020; 33:e13480. [PMID: 32359084 DOI: 10.1111/dth.13480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 11/30/2022]
Abstract
The clinical presentation of primary antiphospholipid syndrome (PAPS) can vary, often mimicking many other medical conditions. Therefore, it is difficult to diagnose at the first presentation because of the absence of classical symptoms. We described an unusual presentation of PAPS mimicking livedoid vasculopathy (LV), where the only diagnostic clue at the initial presentation was skin lesions in both lower legs. A 75-year-old Han Chinese woman presented with features mimicking LV, without clinically significant antiphospholipid syndrome (APS). After many relevant laboratory examinations and histopathological examination, the patient was finally diagnosed as having PAPS. LV should not be treated as an independent disease, but as a skin manifestation. A high degree of suspicion of APS is needed in patients presenting or diagnosed with LV. Early interventions are necessary to prevent and reduce the risk of thrombosis. This case presents a rare clinical manifestation and provides significant information on PAPS.
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Affiliation(s)
- Huinv He
- Department of Pathology, The central hospital of Xianyang City, Xianyang, Shaanxi, China
| | - Ning Wu
- Department of Dermatology, The central hospital of Xianyang City, Xianyang, Shaanxi, China
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12
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Georgesen C, Fox LP, Harp J. Retiform purpura: Workup and therapeutic considerations in select conditions. J Am Acad Dermatol 2020; 82:799-816. [DOI: 10.1016/j.jaad.2019.07.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/15/2019] [Accepted: 07/28/2019] [Indexed: 02/07/2023]
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13
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Bezerra AS, Andrade ADAAJD, Polimanti AC, Fürst RVDC, Criado PR, Corrêa JA. Livedoid Vasculopathy: diagnosis and treatment in pregnant women. J Vasc Bras 2020; 19:e20190093. [PMID: 34178061 PMCID: PMC8202189 DOI: 10.1590/1677-5449.190093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Livedoid Vasculopathy is a disease characterized by occlusion of the capillaries of
the dermis, without inflammatory signs. It begins with purpuric papules or macules
that develop into painful ulcers, mainly involving the ankles and feet. In this case
report, we describe diagnosis and treatment in a young pregnant patient, with
excellent clinical response.
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14
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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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15
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Weishaupt C, Strölin A, Kahle B, Kreuter A, Schneider SW, Gerss J, Eveslage M, Drabik A, Goerge T. Characteristics, risk factors and treatment reality in livedoid vasculopathy - a multicentre analysis. J Eur Acad Dermatol Venereol 2019; 33:1784-1791. [PMID: 31009111 DOI: 10.1111/jdv.15639] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
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).
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Affiliation(s)
- C Weishaupt
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
| | - A Strölin
- Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - B Kahle
- Department of Dermatology, University Hospital Luebeck, Luebeck, Germany
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, University Witten/Herdecke, Oberhausen, Germany
| | - S W Schneider
- Department of Dermatology, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - J Gerss
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - M Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - A Drabik
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
| | - T Goerge
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
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16
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Parsi K, Kang M, Abbott L. Livedo vasculopathy: Ablation of the affected vessels to prevent recurrent ulcerations. Phlebology 2019; 34:582-597. [PMID: 30691377 DOI: 10.1177/0268355519825894] [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: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Kurosh Parsi
- Department of Dermatology, St. Vincent's Hospital, Sydney, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research (AMR), St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Mina Kang
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Lisa Abbott
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research (AMR), St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Australia
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17
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Freitas TQ, Halpern I, Criado PR. Livedoid vasculopathy: a compelling diagnosis. AUTOPSY AND CASE REPORTS 2018; 8:e2018034. [PMID: 30101138 PMCID: PMC6066260 DOI: 10.4322/acr.2018.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 07/01/2018] [Indexed: 11/23/2022] Open
Affiliation(s)
- Thiago Quadrante Freitas
- Universidade de São Paulo (USP), Faculty of Medicine, Internal Medicine Department. São Paulo, SP, Brazil
| | - Ilana Halpern
- Universidade de São Paulo (USP), Hospital das Clínicas, Dermatopathology Laboratory, Dermatology Division. São Paulo, SP, Brazil
| | - Paulo Ricardo Criado
- Universidade de São Paulo (USP), Faculty of Medicine, Department of Dermatology. São Paulo, SP, Brazil.,Faculty of Medicine of ABC, Department of Dermatology. Santo André, SP, Brazil
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19
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Siddique S, Risse J, Canaud G, Zuily S. Vascular Manifestations in Antiphospholipid Syndrome (APS): Is APS a Thrombophilia or a Vasculopathy? Curr Rheumatol Rep 2017; 19:64. [PMID: 28871481 DOI: 10.1007/s11926-017-0687-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Antiphospholipid antibody syndrome (APS) is characterized primarily by thrombosis and pregnancy morbidity. Chronic vascular lesions can also occur. While the underlying mechanisms of these vascular lesions are not entirely known, there have been multiple theories describing the potential process of vasculopathy in APS and the various clinical manifestations associated with it. RECENT FINDINGS Recently, it has been demonstrated that endothelial proliferation in kidneys can be explained by the activation of the mammalian target of rapamycin complex (mTORC) pathway by antiphospholipid antibodies (aPL). These data support the existence of an APS-related vasculopathy in different locations which can explain-in part-the different manifestations of APS. This review focuses on the various manifestations of APS as a result of APS-related vasculopathy, as well as pathophysiology, current screening, and treatment options for clinicians to be aware of.
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Affiliation(s)
- Salma Siddique
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA.
| | - Jessie Risse
- CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases, Inserm U1116 at Lorraine University, Nancy, France
| | - Guillaume Canaud
- Université Paris Descartes, Sorbonne Paris Cité; Inserm U1151, Institut Necker-Enfants Malades; Service de Néphrologie Transplantation Adultes, Hôpital Necker-Enfants Malades, Paris, France
| | - Stéphane Zuily
- CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases, Inserm U1116 at Lorraine University, Nancy, France
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Abstract
Livedoid vasculopathy (atrophie blanche) is a form of thrombotic vasculopathy. It is characterized by small ulcers that become crusted, and heal after several months to produce white atrophic scars. The most commonly affected sites are the lower legs, in particular the dorsum of the feet and ankles. To date, the dermoscopic features of livedoid vasculopathy have not been clearly described in the literature. In this observational study, we sought to evaluate the dermoscopic patterns of livedoid vasculopathy and determine whether the dermoscopic features are associated with certain histopathological characteristics. We evaluated 9 patients with livedoid vasculopathy by dermoscopy. Skin biopsy specimens were stained with hematoxylin and eosin for histopathologic examination, and dermoscopic features were correlated with histopathological characteristics. In the majority of patients with livedoid vasculopathy, examination with dermoscopy revealed central crusted ulcers or ivory white areas associated with peripheral pigmentation in a reticular pattern. In addition, increased vascular structures including linear and glomerular vessels were found. On histopathological examination, the central ivory white areas correlated with dermal fibrosis, the reticular pigmentation corresponded to epidermal basal layer hyperpigmentation or melanin within melanophages in the dermal papillae, and the vascular structures correlated with dilatation and proliferation of capillaries in the upper dermis. In summary, the most common dermoscopic features of livedoid vasculopathy identified in this study were central crusted ulcers or ivory white scar-like areas associated with peripheral reticular pigmentation and increased vascular structures. The characterization of dermoscopic criteria for livedoid vasculopathy may improve the accuracy in the clinical diagnosis and follow-up of this disease.
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Affiliation(s)
- Stephen Chu-Sung Hu
- Department of Dermatology, College of Medicine, Kaohsiung Medical University
- Department of Dermatology, Kaohsiung Medical University Hospital
| | - Gwo-Shing Chen
- Department of Dermatology, College of Medicine, Kaohsiung Medical University
- Department of Dermatology, Kaohsiung Medical University Hospital
| | - Chi-Ling Lin
- Department of Dermatology, Kaohsiung Medical University Hospital
- Department of Dermatology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung
| | - Yang-Chun Cheng
- Department of Dermatology, Kaohsiung Medical University Hospital
| | - Yung-Song Lin
- Department of Otolaryngology, Chi Mei Medical Center
- Center of General education, Southern Taiwan University of Technology, Tainan City
- Department of Otolaryngology, School of Medicine, Taipei Medical University, Taipei, Taiwan
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Provenza JR, Pedri LE, Provenza GM. Livedoid vasculopathy. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:554-556. [PMID: 27914604 DOI: 10.1016/j.rbre.2016.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 09/25/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- José Roberto Provenza
- Pontifícia Universidade Católica de Campinas, Hospital e Maternidade Celso Pierro, Serviço de Reumatologia, Campinas, SP, Brazil
| | - Lucas Eduardo Pedri
- Pontifícia Universidade Católica de Campinas, Hospital e Maternidade Celso Pierro, Serviço de Reumatologia, Campinas, SP, Brazil.
| | - Gabriel Mesquita Provenza
- Pontifícia Universidade Católica de Campinas, Hospital e Maternidade Celso Pierro, Serviço de Radiologia, Campinas, SP, Brazil
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22
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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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Yamaguchi Y, Nakazato S, Izumi K, Ieko M, Nomura T, Shimizu H. Rapid remission of severe pain from livedoid vasculopathy by apixaban. J Eur Acad Dermatol Venereol 2016; 31:e45-e46. [DOI: 10.1111/jdv.13691] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Y. Yamaguchi
- Department of Dermatology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - S. Nakazato
- Department of Dermatology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - K. Izumi
- Department of Dermatology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - M. Ieko
- Department of Internal Medicine; School of Dentistry; Health Sciences University of Hokkaido; Ishikari-Tobetsu Japan
| | - T. Nomura
- Department of Dermatology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - H. Shimizu
- Department of Dermatology; Hokkaido University Graduate School of Medicine; Sapporo Japan
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24
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Provenza JR, Pedri LE, Provenza GM. Livedoid vasculopathy. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:S0482-5004(16)00027-9. [PMID: 26952873 DOI: 10.1016/j.rbr.2015.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 08/26/2015] [Accepted: 09/25/2015] [Indexed: 11/16/2022] Open
Abstract
Livedoid vasculopathy is a chronic and painful skin disease that progresses to ulceration. Due to its uncertain pathogenesis, there is no single effective treatment for this condition, and current therapeutic options are based on isolated case reports, or on case series. We report a case of a female patient with livedoid vasculopathy, which achieved excellent healing of lower limb ulcers after using an anti-TNF agent.
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Affiliation(s)
- José Roberto Provenza
- Serviço de Reumatologia, Hospital e Maternidade Celso Pierro, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brasil
| | - Lucas Eduardo Pedri
- Serviço de Reumatologia, Hospital e Maternidade Celso Pierro, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brasil.
| | - Gabriel Mesquita Provenza
- Serviço de Radiologia, Hospital e Maternidade Celso Pierro, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brasil
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25
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Allenbach Y, Tourte M, Stenzel W, Goebel HH, Maisonobe T, Frances C, Barete S, Benveniste O. Expanding the spectrum of livedoid vasculopathy: peculiar neuromuscular manifestations. Neuropathol Appl Neurobiol 2015; 41:849-52. [DOI: 10.1111/nan.12243] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Yves Allenbach
- Department of Neuropathology; Charité - Universitätsmedizin; Berlin Germany
- Department of Internal Medicine and Clinical Immunology; Hospital University Department: Inflammation, Immunopathology and Biotherapy (DHU i2B); Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital; Paris France
- Inflammatory Muscle Team; Inserm U974; Sorbonne Université; Paris France
| | - Maylis Tourte
- Department of Internal Medicine and Clinical Immunology; Hospital University Department: Inflammation, Immunopathology and Biotherapy (DHU i2B); Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital; Paris France
- Inflammatory Muscle Team; Inserm U974; Sorbonne Université; Paris France
| | - Werner Stenzel
- Department of Neuropathology; Charité - Universitätsmedizin; Berlin Germany
| | - Hans-Hilmar Goebel
- Department of Neuropathology; Charité - Universitätsmedizin; Berlin Germany
| | - Tierry Maisonobe
- Assistance Publique-Hôpitaux de Paris; Department of Neuropathology; Pitié-Salpêtrière University Hospital; Paris France
| | - Camille Frances
- Assistance Publique - Hôpitaux de Paris; Tenon University Hospital; Department of Dermatology; Sorbonne University; Paris France
| | - Stephane Barete
- Assistance Publique - Hôpitaux de Paris; Tenon University Hospital; Department of Dermatology; Sorbonne University; Paris France
- Assistance Publique - Hôpitaux de Paris; Pitié-Salpêtrière University Hospital; Dermatology unit; Sorbonne University; University Pierre et Marie-Curie-Paris 6; Paris France
| | - Olivier Benveniste
- Department of Internal Medicine and Clinical Immunology; Hospital University Department: Inflammation, Immunopathology and Biotherapy (DHU i2B); Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital; Paris France
- Inflammatory Muscle Team; Inserm U974; Sorbonne Université; Paris France
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26
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Criado PR, de Souza EspinelI DP, Valentef NS, Alavi A, Kirsner RS. Livedoid vasculopathy and high levels of lipoprotein (a): response to danazol. Dermatol Ther 2015; 28:248-53. [DOI: 10.1111/dth.12225] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paulo Ricardo Criado
- Dermatology, Dermatology Sao Paulo; Hospital das Clínicas da Faculdade de Medicina da USP
| | | | | | - Afsaneh Alavi
- Medicine (Dermatology); University of Toronto; Toronto Ontario Canada
| | - Robert S. Kirsner
- Dermatology and Cutaneous Surgery; University of Miami; Miami Florida
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Sharma AM, Singh S, Lewis JE. Diagnostic approach in patients with suspected vasculitis. Tech Vasc Interv Radiol 2014; 17:226-33. [PMID: 25770635 DOI: 10.1053/j.tvir.2014.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Vasculitides are a heterogeneous group of disorders that share the common feature of inflammation of the blood vessel wall. Vasculitis can be a systemic or localized process and depending on the disorder can affect large, medium, or small vessels. Vascular physicians including interventional radiologists often may be involved early in these cases before the establishment of a diagnosis as these patients may present with manifestations attributable to occlusive vascular syndromes. In this article, we discuss the presenting signs and symptoms of patients with vasculitis as well as laboratory and imaging studies required to further evaluate these disorders and treatment options, which include interventional as well as noninterventional options.
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Affiliation(s)
- Aditya M Sharma
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA.
| | - Shailendra Singh
- Division of Rheumatology, Department of Internal Medicine University of Virginia School of Medicine, Charlottesville, VA
| | - Janet E Lewis
- Division of Rheumatology, Department of Internal Medicine University of Virginia School of Medicine, Charlottesville, VA
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28
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Quality-of-life impairment in patients with livedoid vasculopathy. J Am Acad Dermatol 2014; 71:1024-6. [DOI: 10.1016/j.jaad.2014.06.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 05/25/2014] [Accepted: 06/05/2014] [Indexed: 11/20/2022]
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29
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Lima RSA, Maquiné GÁ, Talhari C, Encarnação ICL, Schettini APM, Santos M. Livedoid vasculopathy as a marker of systemic disease: report of two cases. An Bras Dermatol 2014; 89:822-4. [PMID: 25184928 PMCID: PMC4155967 DOI: 10.1590/abd1806-4841.20142897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 09/14/2013] [Indexed: 11/22/2022] Open
Abstract
The livedoid vasculopathy is an obstructive vascular process of etiology not yet
fully known, being possibly associated with several prothrombotic events. It is
clinically characterized by the presence of painful and recurring purpuric lesions,
which usually suffer ulceration and evolve with formation of white atrophic scars
usually located in the lower limbs. Two cases are here reported of painful ulcerated
lesions on the lower limbs, in which the identification of VL enabled the diagnosis
of systemic diseases.
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30
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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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31
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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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32
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Vascular disease in systemic lupus erythematosus. Autoimmune Dis 2012; 2012:876456. [PMID: 22957213 PMCID: PMC3432322 DOI: 10.1155/2012/876456] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 08/03/2012] [Indexed: 01/09/2023] Open
Abstract
Vascular disease, either as a direct complication of the disease or developing as an accompanying comorbidity impairs significantly the quality of life of patients with SLE and represents the most frequent cause of death in established lupus. This paper aims to give an overview of the prevalence of the different forms of vasculopathy that can be encountered in a lupus patient, describe their pathogenesis, and address their impact on disease severity and outcome.
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