06/22/2014    

Livedoid vasculopathy?

This patient is a 29 year old, healthy appearing,
white male who first presented to me approximately
a year ago with a "sore" on the top of his left
foot which he stated developed a few weeks prior
after he'd walked several mile home from work
while wearing his work boots. He'd been applying
antibiotic ointment to it and covering it with a
Band-aid but it was not getting better.

In addition to this, he complained of "skin pain"
and gradual discoloration of the skin over the
past several years. He related this to Raynauds
that he has "had forever." Patient's medical
history was significant for HTN and asthma for
which he takes lisinopril 20mg qd, nifedipine ER
30 mg qd, singular 10mg qd, proair HFA 2 puffs q
4 hours HFA. He reported allergies to serevent and
pulmocort in addition to environmental allergies.
Patient was a smoker but stopped shortly after his
initial visit last July.

The ulceration took several weeks to heal with
local wound care and DNA custom compounded gel.
Studies done during this time included ABIs, CBC,
glucose all of which were within normal limits.
In November the patient represented with new
ulcerations - this time on both feet. He
requested referral to an out-of-town wound care
center. There a biopsy was done showing "skin with
spongiotic dermatitis and underlying dermal
fibrosis."

Pedal and chest radiographs were all non-
contributory and standard hematologic and
chemistry workups were also all WNL. During this
time his "skin pain" increased and lidocaine 5%
ointment was prescribed for him to apply to his
feet at night. The skin ulcerations have continued
to wax and wane leaving the patient frustrated.
He no longer desired to travel to the wound care
center and recently represented to me. Some
research has led me to suspect a livedoid
vasculopathy.

The following were recently ordered and all
returned WNL - PT, PTT, uric acid, CRP-HS, ESR,
ANA, RF and Aphos. Attached is a recent photo
showing areas of atrophy blanche at the sites of
prior ulceration. I would appreciate any comments
or suggestions as to any further testing or the
most appropriate referral.

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