Livedoid vasculopathy: how to diagnose and how to treat?

Clinical analysis of skin lesions in livedoid vasculopathy: a study of 46 Chinese patients

BACKGROUND

Clinical data regarding cutaneous manifestations in Chinese patients with livedoid vasculopathy (LV) are limited.

OBJECTIVES

To assess clinical features of skin lesions in LV, especially the characteristics of extensive livedo reticularis and pigmented purpuric dermatosis-like lesions in these patients.

METHODS

This was a single-center retrospective study of 46 Chinese patients with LV between March 2021 and July 2021. The characteristics of skin lesions in LV were described in detail.

RESULTS

A total of 29 females and 17 males were included in this study, with a mean age of 27.7 years (ranging from 13 to 51 years). Twenty (43.5%) patients developed their first skin lesions before age 18. Among 46 patients, 33 presented livedo reticularis with 78.8% (n = 26) of these patients whose livedo reticularis was extensive. Seven patients had lesions simulating pigmented purpuric dermatosis, including four cases of pigmented purpura and three cases of telangiectatic purpura. Numbness was found in 16 patients, mainly in the lower limbs (62.5%), ankles (31.3%), and dorsum of the feet (18.8%).

CONCLUSIONS

For patients with symptoms of extensive livedo reticularis, retiform purpura, or numbness, it is necessary to make a differential diagnosis.

Pain Management Options in a Patient with Livedoid Vasculopathy and Peripheral Neuropathy

Livedoid vasculopathy (LV) is a rare clinical condition presenting as painful lesions mostly on the lower extremities. We present a case of LV with peripheral neuropathy in a young man initially misdiagnosed and treated for cellulitis. He was started on aspirin, pentoxifylline and apixaban immediately after the diagnosis of LV. However, pain management was a real challenge for the clinicians. Hence, he was later treated with epoprostenol and amlodipine for vasodilation, steroids for any possible inflammation, and antibiotics to treat superimposed infection. Irrespective of all the above, his pain was uncontrollable, and he finally received ketamine infusions along with narcotics, achieving better pain control. Various studies support the use of intravenous immunoglobulin and anti-TNF agents for pain relief in idiopathic and secondary LV. Intermittent low-dose dabigatran has also been found to be effective in the maintenance of remission in LV. However, no large studies have yet been conducted to confirm the efficacy of these medications.

LEARNING POINTS

Early initiation of treatment with antiplatelets and anticoagulants is recommended to prevent the progression of livedoid vasculopathy (LV).Anti-TNF agents can be tried in refractory LV for rapid relief of pain.Intravenous immunoglobulin has been shown to be effective for the resolution of pain and improvement of neuropathic symptoms especially in LV refractory to immunosuppressive agents.

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

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