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Dermatopathology: Practical & Conceptual July - September 2005
4. Understanding livedo vasculitis: Part I—A glossary, in historical perspective, of terms related to "livedo" and "livedo vasculitis"
K. C. Nischal, M.D.
Almut Böer, M.D.
1860: livedo reticularis
1907: livedo racemosa
1929: atrophie blanche
capillarite télangiectasique et atrophiante
capillarites sclérosantes et atrophiantes
1953: capillaritis alba
1955: livedo reticularis with summer ulceration
1956: livedo reticularis with ulcerations
1957: atrophia alba
1965: Sneddon syndrome
1966: periodic painful ulcers of lower extremities
1967: livedo vasculitis
1967: segmental hyalinizing vasculitis
1974: livedoid vasculitis
1974: livedo reticulosis
1974: vasculitis of atrophie blanche
1983: PURPLE (painful purpuric ulcers with reticular patterning on the lower extremities)
1992: livedo vasculopathy
1998: livedoid vasculopathy
Suggestion for terminology
I. Useful terms
II. Confusing terms—to be avoided
III. Antiquated terms—not to be used any more
1955: livedo reticularis with summer ulceration
The term "livedo reticularis with summer ulceration" is attributed to Feldaker et al. who used it, in 1955, for a condition that they had observed in 12 patients, all of them women in their Middle Ages. [
] Findings clinical were described by the authors as livedo reticularis
livedo reticularis) in association with edema and "painful, red-to-purple, hemorrhagic or infarctive area" as well as ulcers with irregular shape and various sizes. The soles, the dorsa of the feet, the ankles, and the shins were affected most commonly (
In their article of 1955, Feldaker et al. included pictures of lesions clinical of two of their patients. In both, there are no signs of livedo reticularis. The branched appearance of erythema shown in Fig 2 A, however, qualifies to be designated livedo racemosa. Macules of livedo vasculitis are not always branched; they may also have a blotchy appearance as can be seen in Fig 2 B. Lesions in both patients consisted of erythema, ulceration, and white stellate atrophic lesions.
Findings histopathologic were studied in only 7 of the 12 patients. Four of them showed "thickening of the wall of the arterioles in the cutis and subcutis and occlusion of these vessels, and of these, in two cases the arteriole revealed occlusion by an amorphous pink thrombus." Biopsy specimens taken from the other three patients showed "thickening of the walls, some fibrosis and obliteration of the lumen of the vein." Moreover, the authors noted "a mild to moderate nonspecific infiltrate in the corium which was usually perivascular with some infiltration of the occluded arterioles and veins." The condition was said by the authors to be unassociated with varicosis. They also noted that "there was no essential difference in the type of vessel involvement in the histopathologic picture of summer ulcerations or winter ulcerations with livedo reticularis." Pictures of lesions clinical and photomicrographs of sections of tissue from two patients were included by the authors in their report.
Two of the patients published by Feldaker et al. had been reported on earlier by O'Leary and colleagues. [
] In 1943, they had told of a 36-year-old woman with "recurring crops of small painful ulcers about the ankles and dorsa of the feet" that appeared each year during the summer months. Examination clinical revealed "bluish retiform mottling of the skin of the extremities, particularly of the legs," accompanied by edema around the ankles but unassociated with varicosis. Studies by conventional microscopy were not performed by the author at that time. In 1954, O'Leary presented another patient, a 47-year-old woman who also had "recurrent painful ulcerations about the ankles" associated with livedo reticularis. Ulcers were said to have recurred only during summer. The patient had no signs of varicosis. A biopsy specimen revealed, according to the article by Feldaker et al. an "arteriole in the subcutaneous tissue show[ing] thickened wall, intimal proliferation, and narrowed lumen."
Nowhere in their reports did either O'Leary or Feldaker make mention of a condition termed atrophie blanche. The colleagues seemed to have been unaware of previous reports about the findings very similar to their own published in the French and the German literature of dermatology under that designation. And it was only in the very same year, 1955, that Nelson reported on his experience with six patients in whom he had made the diagnosis of atrophie blanche. [
] The descriptions of findings clinical, however, in patients reported on by O'Leary or Feldaker is remarkably similar to what Nelson described in some of his patients. What O'Leary and Feldaker were referring to as livedo reticularis was, in actuality, a branched pattern of livedo, i.e., livedo racemosa.
In sum, even though Feldaker et al., in 1955, claimed to report on a new syndrome, the condition observed by them had already been described in the English language, in 1944, by O'Leary, who also was the first to use the designation "livedo reticularis with summer ulceration." Neither O'Leary nor Feldaker knew about reports in French, German publications about the very same disease
atrophie blanche and
capillarite télangiectasique et atrophiante),
and they used the term livedo reticularis when actually referring to livedo racemosa.
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