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Successful Treatment of Livedoid Vasculitis with Primary Antiphospholipid Syndrome by Using Aspirin and Low Dose Warfarin Combination Therapy

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Letter to the Editor

614 Ann Dermatol

Received February 28, 2014, Revised October 13, 2014, Accepted for publication November 6, 2014

Corresponding author: Sang Wook Son, Department of Dermatology, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan 15355, Korea. Tel: 82-31-412-5180, Fax: 82-31-412-4208, E-mail: skin4u@korea.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://

creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

http://dx.doi.org/10.5021/ad.2015.27.5.614

Successful Treatment of Livedoid Vasculitis with

Primary Antiphospholipid Syndrome by Using Aspirin and Low Dose Warfarin Combination Therapy

Byoung Joon So, Jae Beom Park, Min Gun Yoo, Il-Hwan Kim, Sang Wook Son

Department of Dermatology, Korea University Ansan Hospital, Korea University School of Medicine, Ansan, Korea

Dear Editor:

Livedoid vasculitis is a rare disorder clinically charac- terized by purpuric macules and papules on the lower legs and feet1. These lesions are caused by infarction of small vessels that affects young and middle-aged women.

The bizarrely shaped ulcers may be painful, heal slowly, result in scarring, or cause atrophie blanche2. Livedoid vasculitis usually occurs in isolation; however, several re- ports have shown an association with systemic lupus er- ythematosus, other autoimmune diseases, and malignant disease3. However, an association with antiphospholipid antibodies has been rarely described.

Antiphospholipid syndrome is an acquired hypercoagulable state, shows recurrent thrombosis, and can spontaneously resolve. It is correlated with systemic lupus erythematosus in about half of the patients. There are only a few reports about patients with livedoid vasculitis accompanying pri- mary antiphospholipid syndrome without systemic lupus erythematosus. Primary antiphospholipid syndrome could be diagnosed by using the criteria of Miyakis et al.4 (small vessel thrombosis, spontaneous abortion/anticardiolipin an- tibody subclass immunoglobulin (Ig) G or IgM, anti-β2 gly- coprotein IgG or IgM, and lupus anticoagulant).

A 33-year-old female patient with painful tender eryth-

ematous ulcers on both lower legs visited our hospital in December 2012. The ulcers had been covered with exu- date and crust for 4 months. She had been treated with a nonsteroidal anti-inflammatory drug for several months be- fore visiting our institution. Irregular ulceration and pur- pura were observed on admission (Fig. 1A). Histological examination showed evidence of dilated capillaries in the upper dermis and thickened vessel walls containing fi- brinoid materials (Fig. 2). She was initially treated with systemic methylprednisolone, but she failed to respond.

Screening for vasculitis gave normal results, including lu- pus relevant antibodies (lupus anticoagulant, antinuclear antibody, and anti-dsDNA antibody), except for the increase in anti-cardiolipin antibody subclass IgG at 17.2 U/ml (reference, <9 U/ml) and a markedly increased anti-car- diolipin antibody subclass IgA at 20.8 U/ml (reference,

<10 U/ml). Additionally, she had increased anti-phospho- lipid antibody subclass IgG at 18.4 U/ml. Therefore, the diagnosis was concluded to be livedoid vasculitis and pri- mary antiphospholipid syndrome, and she was started on combination therapy with 100 mg aspirin and low-dose warfarin (2 mg) daily with a good clinical response (Fig.

1B). She remains in remission presently.

The treatment for livedoid vasculitis with antiphospholipid syndrome is not clearly defined. Corticosteroids have been used successfully5; however, they do not provide long-term benefits, and our patient showed no response. Antithrom- botic agents, including tissue plasminogen activator, pros- tacyclin, antiplatelet therapy, and low-dose warfarin, can be used successfully1-3. The combination of low-dose war- farin and antiplatelet therapy was used in our patient to prevent further thrombosis.

The patient demonstrated histologically thickened vessel walls containing fibrinoid material and clinically irregular ulcerations and purpura. Therefore, her condition was di-

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Letter to the Editor

Vol. 27, No. 5, 2015 615 Fig. 1. (A) Lesions showing purpura and irregular ulcerations at first visit. (B) Lesions showing almost complete clinical remission at 2 months after treatment.

Fig. 2. (A) Dilated capillaries in the upper dermis (H&E, ×40). (B) Vessel walls are thickened and contain fibrinoid material (H&E, ×100).

agnosed as livedoid vasculitis with primary antiphospholipid syndrome and she was treated with low-dose warfarin, an antiplatelet agent.

Livedoid vasculitis presents the clinical symptoms of other diseases that cause occlusive vasculopathy; thus, clini- cians should find the underlying conditions and provide treatment if antiphospholipid antibodies are present. Aspirin and low-dose warfarin combination therapy is a valuable therapeutic option for livedoid vasculitis with primary an- tiphospholipid syndrome.

REFERENCES

1. Kim JE, Park SY, Sinn DI, Kim SM, Hong YH, Park KS, et al.

Ischemic neuropathy associated with livedoid vasculitis. J Clin Neurol 2011;7:233-236.

2. Grasland A, Crickx B, Blanc M, Pouchot J, Vinceneux P.

Livedoid vasculopathy (white atrophy) associated with anti- cardiolipin antibodies. Ann Med Interne (Paris) 2000;151:

408-410.

3. Kim JE, Park HJ, Lee JY, Cho BK. A case of leg ulcer with SLE and antiphospholipid syndrome. Korean J Dermatol 2006;

44:738-740.

4. Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al. International consensus statement on an update of the classification criteria for definite antipho- spholipid syndrome (APS). J Thromb Haemost 2006;4:

295-306.

5. Acland KM, Darvay A, Wakelin SH, Russell-Jones R.

Livedoid vasculitis: a manifestation of the antiphospholipid syndrome? Br J Dermatol 1999;140:131-135.

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