Livedoid vasculopathy: A mimicker of vasculitis

A 23-year-old female presented with erythematous to violaceous discolouration of the skin in all four limbs for the past 4 months, which progressed to form painful non-healing ulcers in both lower limbs.Examination revealed livedo racemosa with necrotic ulcers in both lower limbs (Figs.1a and b).Immunological tests were negative for anti-nuclear antibodies, extractable nuclear antigen profile, MPO and PR-3 autoantibodies, cryoglobulins, and antiphospholipid antibodies.Imaging, serum protein electrophoresis, and serum free light chain assay ruled out underlying haematolymphoid malignancies.Skin biopsy showed fibrin deposition in small vessels with mild lymphocytic infiltrate, occasional neutrophils and neutrophilic debris with no evidence of fibrinoid necrosis.She was managed as idiopathic livedoid vasculopathy, also known as porcelain white ulcers or atrophie blanche (Fig. 1c), with apixaban and aspirin, with complete healing of ulcers.Livedoid vasculopathy is a rare coagulation disorder characterized by livedo racemosa and painful ulcerations, which lead to porcelain-white, atrophic scars on healing.1,2 It is imperative to differentiate this entity from small vessel vasculitis and antiphospholipid syndrome.