Skip to main content
Log in

Livedoid vasculopathy: does hyperhomocysteinaemia play an aetiological role?

  • Clinical Report
  • Published:
European Journal of Dermatology Aims and scope

Abstract

Background

Livedoid vasculopathy (LV) has been shown to be associated with hypercoagulability. However, relevant genetic and exogenous thrombophilic factors are not fully determined.

Objectives

To evaluate the frequency of hyperhomocysteinaemia (HHCE) and genotypes of hypercoagulative factors in LV patients.

Material and Methods

Plasma homocysteine level was measured in 42 LV patients. Polymorphism of MTHFR (677C>T and 1298A>C), PAI1 (-675 5G/4G and -844A>G), and F2 (20210G>A), and the F5 Leiden mutation, as well as biochemical parameters for hypercoagulability, were analysed.

Results

Of the LV patients, 62% revealed mild HHCE. Polymorphisms of MTHFR were observed in 75% and 56% and the PAI1 -675 5G/4G polymorphism in 100% and 83% of patients with and without HHCE, respectively. All LV patients with renal failure had mild HHCE. A high level of comorbidity of hypertension (99%) and diabetes type 2 (44%) were noted.

Conclusion

HHCE seems to play a major pathogenetic role in LV. A high prevalence of further procoagulative factors might support the view that LV is a “complex disease”.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Criado PR, Rivitti EA, Sotto MN, et al. Livedoid vasculopathy: an intriguing cutaneous disease. An Bras Dermatol 2011; 86: 961–77.

    Article  Google Scholar 

  2. Kerk N, Goerge T. Livedoid vasculopathy - current aspects of diagnosis and treatment of cutaneous infarction. J Dtsch Dermatol Ges 2013; 11: 407–10.

    PubMed  Google Scholar 

  3. Alavi A, Hafner J, Dutz JP, et al. Livedoid vasculopathy: an indepth analysis using a modified Delphi approach. J Am Acad Dermatol 2013; 69: 1033–42.

    Article  Google Scholar 

  4. Feldaker M, Hines EA Jr., Kierland RR. Livedo reticularis with summer ulcerations. Arch Dermatol 1955; 72: 31–42.

    Article  CAS  Google Scholar 

  5. Yang L, Murota H, Shindo S, et al. Increased serum CXCR2 ligand levels in livedo vasculopathy with winter ulcerations: possible contribution of neutrophil recruitment to lesional skin. J Dermatol Sci 2016; 82: 57–9.

    Article  CAS  Google Scholar 

  6. Bard JW, Winkelmann RK. Livedo vasculitis. Segmental hyalinizing vasculitis of the dermis. Arch Dermatol 1967; 96: 489–99.

    Article  CAS  Google Scholar 

  7. Patterson JW. The vasculopathic reaction pattern. Weedon’s Skin Pathology, 4th ed. Elsevier, 2016: 219-80.

  8. Hafner J, Nobbe S, Partsch H, et al. Martorell hypertensive ischemic leg ulcer: a model of ischemic subcutaneous arteriolosclerosis. Arch Dermatol 2010; 146: 961–8.

    Article  Google Scholar 

  9. Hairston BR, Davis MD, Pittelkow MR, Ahmed I. Livedoid vasculopathy: further evidence for procoagulant pathogenesis. Arch Dermatol 2006; 142: 1413–8.

    Article  Google Scholar 

  10. Criado PR, Rivitti EA, Sotto MN, de Carvalho JF. Livedoid vasculopathy as a coagulation disorder. Autoimmun Rev 2011; 10: 353–60.

    Article  Google Scholar 

  11. Didier AF, Tourand JP, Collet E, Dalac S, Becker F, Lambert D. Nécrose cutanée distale, une étiologie inhabituelle: l’hyperhomocystéinémie. Ann Dermatol Vénéréol 1999; 126: 822–5.

    CAS  PubMed  Google Scholar 

  12. Gibson GE, Li H, Pittelkow MR. Homocysteinemia and livedoid vasculitis. J Am Acad Dermatol 1999; 40: 279–81.

    Article  CAS  Google Scholar 

  13. Meiss F, Marsch WC, Fischer M. Livedoid vasculopathy. The role of hyperhomocysteinemia and its simple therapeutic consequences. Eur J Dermatol 2006; 16: 159–62.

    PubMed  Google Scholar 

  14. Thornsberry LA, LoSicco KI, English JC. 3rd KI. The skin and hypercoagulable states. J Am Acad Dermatol 2013; 69: 450–62.

    Article  Google Scholar 

  15. Allenbach Y, Tourte M, Stenzel W, et al. Expanding the spectrum of livedoid vasculopathy: peculiar neuromuscular manifestations. Neuropathol Appl Neurobiol 2015; 41: 849–52.

    Article  Google Scholar 

  16. Malaguti MC, Cavallaro T, Spezial T, Zorzi MG, Marangoni S, Morini A. Mononeuritis multiplex associated with primary livedoid vasculopathy: neuropathological evidence of ischemic nerve damage. J Neurol Sci 2015; 351: 214–5.

    Article  Google Scholar 

  17. Previtali E, Bucciarelli P, Passamonti SM, Martinelli I. Risk factors for venous and arterial thrombosis. Blood Transfus 2011; 9: 120–38.

    PubMed  PubMed Central  Google Scholar 

  18. Frosst P, Blom HJ, Milos R, et al. A candidate genetic risk factor for vascular disease: a common mutation in methylenetetrahydrofolate reductase. Nat Genet 1995; 10: 111–3.

    Article  CAS  Google Scholar 

  19. van der Put NM, Gabreels F, Stevens EM, et al. A second common mutation in the methylenetetrahydrofolate reductase gene: an additional risk factor for neural-tube defects? Am J Hum Genet 1998; 62: 1044–51.

    Article  CAS  Google Scholar 

  20. Kluft C, Jie AF, Rijken DC, Verheijen JH. Daytime fluctuations in blood of tissue-type plasminogen activator (t-PA) and its fast-acting inhibitor (PAI-1). Thromb Haemost 1988; 59: 329–32.

    Article  CAS  Google Scholar 

  21. Saidi S, Slamia LB, Mahjoub T, Ammou SB, Almawi WY. Association of PAI-1 4G/5G and -844G/A gene polymorphism and changes in PAI-1/tPA levels in stroke: a case-control study. J Stroke Cerebrovasc Dis 2007; 16: 153–9.

    Article  Google Scholar 

  22. Cesari M, Pahor M, Incalzi RA. Plasminogen activator inhibitor-1 (PAI-1): a key factor linking fibrinolysis and age-related subclinical and clinical conditions. Cardiovasc Ther 2010; 28: e72–91.

    Article  CAS  Google Scholar 

  23. Deng A, Gocke CD, Hess J, Heyman M, Paltiel M, Gaspari A. Livedoid vasculopathy associated with plasminogen activator inhibitor-1 promoter homozygosity (4G/4G) treated successfully with tissue plasminogen activator. Arch Dermatol 2006; 142: 1466–9.

    PubMed  Google Scholar 

  24. Antunes J, Filipe P, Andre M, Fraga A, Miltenyi G, Marques Gomes M. Livedoid vasculopathy associated with plasminogen activator inhibitor-1 promoter homozygosity (4G/4G) and prothrombin G20210A heterozygosity: response to t-PA therapy. Acta Derm Venereol 2010; 90: 91–2.

    Article  CAS  Google Scholar 

  25. Connors JM. Thrombophilia testing and venous thrombosis. N Engl J Med 2017; 377: 2297–8.

    Article  Google Scholar 

  26. Asselbergs FW, Williams SM, Hebert PR, et al. Gender-specific correlations of plasminogen activator inhibitor-1 and tissue plasminogen activator levels with cardiovascular disease-related traits. J Thromb Haemost 2007; 5: 313–20.

    Article  CAS  Google Scholar 

  27. Chapin JC, Hajjar KA. Fibrinolysis and the control of blood coagulation. Blood Rev 2015; 29: 17–24.

    Article  CAS  Google Scholar 

  28. Turner RH, Ryan TJ. Fibrinolytic activity in human skin. Trans St Johns Hosp Dermatol Soc 1969; 55: 212–7.

    CAS  PubMed  Google Scholar 

  29. Turner RH, Kurban AK, Ryan TJ. Fibrinolytic activity in human skin following epidermal injury. J Invest Dermatol 1969; 53: 458–62.

    Article  CAS  Google Scholar 

  30. Agirbasli M, Goktay F, Peker I, Gunes P, Aker FV, Akkiprik M. Enhanced mRNA expression of plasminogen activator inhibitor-1 in livedoid vasculopathy lesions. Cardiovasc Ther 2017; 35: e12255.

    Article  Google Scholar 

  31. Jacovina AT, Deora AB, Ling Q, et al. Homocysteine inhibits neoangiogenesis in mice through blockade of annexin A2-dependent fibrinolysis. J Clin Invest 2009; 119: 3384–94.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. Goerge T, Weishaupt C, Metze D, et al. Livedoid vasculopathy in a pediatric patient with elevated lipoprotein(a) levels: prompt response to continuous low-molecular-weight heparin. Arch Dermatol 2010; 146: 927–8.

    Article  Google Scholar 

  33. Vasconcelos R, Criado PR, Belda W Jr.. Livedoid vasculopathy secondary to high levels of lipoprotein (a). Br J Dermatol 2011; 164: 1111–3.

    Article  CAS  Google Scholar 

  34. Espinel DPGS, Di Giacomo TB, Pincelli TP, et al. Analysis of serum levels and cutaneous expression of lipoprotein (a) in 38 patients with livedoid vasculopathy. J Cutan Pathol 2017; 44: 1033–7.

    Article  Google Scholar 

  35. van Buuren F, Horstkotte D, Knabbe C, Hinse D, Mellwig KP. Incidence of elevated lipoprotein(a) levels in a large cohort of patients with cardiovascular disease. Clin Res Cardiol Suppl 2017; 1: 44–9.

    Google Scholar 

  36. Kronenberg F. Lipoprotein(a) in various conditions: to keep a sense of proportions. Atherosclerosis 2014; 234: 249–51.

    Article  CAS  Google Scholar 

  37. van Guldener C. Why is homocysteine elevated in renal failure and what can be expected from homocysteine-lowering? Nephrol Dial Transplant 2006; 21: 1161–6.

    Article  Google Scholar 

  38. Micieli R, Alavi A. Treatment for livedoid vasculopathy: a systematic review. JAMA Dermatol 2018; 154: 193–202.

    Article  Google Scholar 

  39. Errichetti E, Stinco G. Recalcitrant livedoid vasculopathy associated with hyperhomocysteinaemia responding to folic acid and vitamins B6/B12 supplementation. Acta Derm Venereol 2016; 96: 987–8.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Ethics declarations

Disclosure. Financial support: none. Conflicts of interest: none.

Additional information

Dedicated to Terence J Ryan (emeritus Professor of Dermatology at Oxford University, United Kingdom) with reference to his earlier fundamental contributions to fibrinolysis in cutaneous tissue.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Marsch, W.C., Komatsuzaki, S., Mueller, A. et al. Livedoid vasculopathy: does hyperhomocysteinaemia play an aetiological role?. Eur J Dermatol 29, 287–293 (2019). https://doi.org/10.1684/ejd.2019.3554

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1684/ejd.2019.3554

Key words

Navigation