title: Livedoid vasculopathy with underlying subcutaneous necrotizing venulitis in an asymptomatic hepatitis B virus carrier: is livedoid vasculopathy a true nonvasculitic disorder?
abstract: Livedoid vasculopathy has been accepted as a nonvasculitic disorder, but authentic vasculitis in the underlying subcutis can occur in cases of collagen disease and polyarteritis nodosa. We report a case of livedoid vasculopathy with underlying subcutaneous necrotizing venulitis in a 42-year-old carrier of hepatitis B virus. The patient also had a 15-year history of ankylosing spondylitis that was currently in remission. Skin lesions revealed superficial ulceration, purpura, atrophie blanche, and reticulate erythema on the lower extremities, and a skin biopsy showed a minimal dermal perivascular lymphocytic infiltrate with marked fibrin thrombi and fibrin deposits along luminal vessel walls, consistent with features of livedoid vasculopathy. However, necrotizing venulitis characterized by a predominant lymphocytic infiltrate in and around the vessel wall with marked fibrinoid vessel wall necrosis was found in the underlying subcutaneous tissue. A direct immunofluorescence study detected immunoglobulin M and C3 deposits in the papillary dermis. The patient responded well to oral aspirin and a prostaglandin analogue and was well controlled with a compression bandage. Vasculitic lesions in the underlying subcutis may have been overlooked in cases in which livedoid vasculopathy has been considered as a nonvasculitic disorder because our case demonstrates that livedoid vasculopathy can be accompanied by subcutaneous vasculitis.
authors.affiliation: Department of Dermatology, Saiseikai Central Hospital, Tokyo, Japan. ishibashi@saichu.jp
authors.forename: Masafumi
authors.initials: M
authors.lastname: Ishibashi
authors.forename: Juria
authors.initials: J
authors.lastname: Miyamoto
authors.forename: Takeshi
authors.initials: T
authors.lastname: Nagasaka
authors.forename: Ko-Ron
authors.initials: KR
authors.lastname: Chen
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000527:Alprostadil / Q000008:administration & dosage / Q000031:analogs & derivatives; D001241:Aspirin / Q000008:administration & dosage; D001706:Biopsy; D002353:Carrier State; D003131:Combined Modality Therapy; D004359:Drug Therapy, Combination; D006509:Hepatitis B / Q000150:complications* / Q000635:transmission; D006801:Humans; D007262:Infusions, Intravenous; D054068:Livedo Reticularis / Q000150:complications / Q000473:pathology* / Q000628:therapy; D008297:Male; D009336:Necrosis; D012867:Skin / Q000098:blood supply* / Q000473:pathology; D013167:Spondylitis, Ankylosing / Q000150:complications*; D053828:Stockings, Compression; D040521:Subcutaneous Tissue / Q000098:blood supply* / Q000473:pathology; D016896:Treatment Outcome; D014657:Vasculitis / Q000150:complications / Q000473:pathology* / Q000628:therapy; D014699:Venules / Q000473:pathology
chemical_list: D000527:Alprostadil; D001241:Aspirin