Treatment of livedoid vasculopathy with low-molecular-weight heparin: report of 2 cases.

A 23-year-old man who was otherwise healthy had a 5-year history of recalcitrant ulcers of the lower extremities. The ulcers worsened in warm weather and during periods of increased physical activity. The ulcers were painful and interfered with his participation in sports, including soccer and basketball. Shallow ulcers and crusting with stellate, porcelain-white scarring and surrounding hyperpigmentation on the lower extremities and dorsal feet were noted on examination (Figure 1). Noninvasive vascular testing, including continuouswave venous Doppler imaging and measurements of the ankle-brachial index and transcutaneous oximetry (TcPO2), revealed moderately to severely reduced TcPO2 levels but no evidence of venous insufficiency. Histopathologic analysis of a skin biopsy specimen from the left ankle was notable for hyalinization of dermal blood vessels in the papillary and superficial reticular dermis and minimal perivascular lymphocytic infiltrate (Figure 2). Direct immunofluorescence study showed superficial vessel deposition of IgG, IgM, and C3 conjugates with patchy deposition of fibrin. Results of laboratory studies, including an extensive screen for coagulation abnormalities, were normal. Taken together, these findings were consistent with a diagnosis of livedoid vasculopathy. Several treatment approaches had been ineffective in controlling ulceration. These approaches included topical corticosteroids, compression therapy, stanozolol, and a triple regimen of pentoxifylline (400 mg, 3 times daily for 29 months), nifedipine (30 mg/d for 21 months), and aspirin (81 mg/d for 29 months).