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Medicina (Buenos Aires)

versión impresa ISSN 0025-7680versión On-line ISSN 1669-9106

Medicina (B. Aires) vol.82 no.4 Ciudad Autónoma de Buenos Aires set. 2022



Medium-pressure hyperbaric oxygen therapy for livedoid vasculopathy

Terapia de oxigenación hiperbárica de media presión en vasculopatía livedoide

Alejandro Herrera-Sánchez1 

María José Madriagal-Alvarado2 

Gabriela Moncayo3 

Fabrizio Verdini3  * 

1 FisioSport Costa Rica, Biobarica Costa Rica

2 Caja Costarricense del Seguro Social, Costa Rica

3 Asociación Argentina de Medicina Hiperbárica e Investigación (AAMHEI), Buenos Aires, Argentina


Livedoid vasculopathy (LV) is a cutaneous manifestation of several diseases that lead to non-inflammatory thrombosis of dermal vessels. We report the case of a 26-year-old female with a 4 years and 8 months-old history of diagnosis of LV and a non-healing ulcer of more than a year of evolution. Because of refractory response to standard care, low-pressure hyperbaric oxygen (LPHBOT) was added to the therapeutic scheme (azathiopine 2.5 mg/kg, folic acid and acetylsalicylic acid). After 12 sessions of LHBOT (60 min, 1.45 ATA ≈100% O2), ulcers achieved complete healing with significant pain relief and no recurrence was present over 6 months. More studies are necessary to determine the effectiveness of HBOT for LV treatment.

Key words: Hyperbaric oxygen therapy; Livedoid vasculopathy; Ulcers


La vasculopatía livedoide (VL) es una manifestación cutánea de varias enfermedades que conducen a una trom bosis no inflamatoria de los vasos dérmicos. Se presenta el caso de una mujer de 26 años con antecedente de diagnóstico de vasculopatía livedoide de 4 años y 8 meses, además de una úlcera no cicatrizante de más de un año de evolución. Debido a la respuesta refractaria a la atención estándar, se añadió oxígeno hiperbárico a baja presión (LPHBOT) al esquema terapéutico (azatriopina 2.5 mg/kg, ácido fólico y ácido acetilsalicílico). Después de 12 sesiones de LHBOT (60 min, 1,45 ATA ≈100% O2), las úlceras tuvieron una curación completa con un alivio significativo del dolor y no hubo recurrencia durante 16 meses. Se necesitan más estudios para determinar la eficacia de TOHB para el tratamiento del VL.

Palabras clave: Terapia de oxigenación hiperbárica; Vasculopatía livedoide; Úlceras

Livedoid vasculopathy (LV) is a rare cutaneous disease that manifests mainly as recurrent leg ulcers. It is also called “atrophie blanche’’ because of its characteristic white scars formed after slowly healing ulcers1,2, LV sig nificantly impairs quality of life3.

LV is a non-inflammatory thrombus occlusive condi tion whose pathogenesis is unknown, associated with coagulation abnormalities or fibrinolysis. Hypoxia and hypercoagulability are the main pathogenic factors with the latter being the most predominant among them1.

Treatment for LV aims to improve skin lesions, al leviate pain and prevent recurrence of the disease. The treatment is controversial, with antithrombotic measures taking precedence over the others. The recurrent nature and controversial pathogenesis make this disorder a very challenging one to treat. Hyperbaric oxygen therapy (HBOT) was used effectively like adjuvant therapy in many cases, improving the healing process and diminishing pain and recurrences4.

HBOT delivers high oxygen concentrations to hy poxic tissue systemically and allows patients to breathe in 100% oxygen while in the pressurized cabin. It is a recognized modality for treating various complex wounds and non-healing ulcers due to various etiologies such as diabetic foot and chronic osteomyelitis4-7. The European Committee of Hyperbaric Medicine recommended treat ment at > 2 atmospheres absolute (ATA) for wounds and burns6,8.

However, the therapeutic benefits of HBOT, like angio genesis, collagen synthesis, anti-inflammatory effect, and bactericidal effect are performed at pressures neurologi cally as safe as under 2 ATA9-11.

High-pressure hyperbaric chambers (between 2 and 2.5 ATA), were used to treat several LV cases4,12-14.

We report a case of this pathology treated with a low-pressure hyperbaric oxygen treatment (lower than 2 ATA).

This case report suggests that low pressure hyperbaric oxygenation therapy is a quick and effective alternative for the treatment of livedoid vasculopathy that does not respond to conventional antiplatelet, immunomodulatory therapy or oral corticosteroids.

Clinical case

A 26-year-old female, non-smoker, presented with a 4 year and 8 months-old history of recurrent multiple non-healing ulcers involving feet and ankles. The wounds were associated with severe pain and inflammation. Examination also revealed evidence of previous ulceration in the form of multiple hyper-pigmented scars on both feet and ankles.

The patient had been undergoing treatment with 2.5 mg / kg azatriopine, 15 mg/day prednisone for 22 days, folic acid and acetylsalicylic acid for two years, which had good results during the first year, but presented poor evolution in the second. A biopsy was performed and the results obtained confirmed the diagnosis of livedoid vasculopathy, for which the treatment with azatriopine was suspended. Histological findings revealed the upper dermis with capillaries with fibrin deposition on their walls and fibrin thrombi with perivascular lymphocytic inflammation and erythrocyte extravasation.

Patient did not give any history of any medical illness. The blood platelets value was within normal parameters. Systemic vasculitis, antiphospholipid syndrome and systemic lupus erythematosus were ruled out. There were no comorbidities or associated pathology.

She reported multiple recurrences in the last year, with higher levels of pain and inflammation, and also the presence of a painful refractory ulcer of a one and a half year-old evolu tion, with dermatitis and small painful macules, papules with purpuric erythematous plaques with small superficial ulcers on both feet. She presented a history of recurrent dermatitis with small, painful ulcers and 4 very strong episodes lasting between 2 and 6 months before.

Hyperbaric oxygen therapy was indicated as adjuvant therapy with a session of 60 min ≈ 100%O2 at 1.45 ATA (Revitalair 430 by Biobarica chamber). The two first weeks the treatment was three times a week and the following weeks was twice a week.

Complete healing and significant pain reduction was ob served after 12 sessions (Fig. 1). Follow-up was indicated to evaluate relapse-free time. The patient referred relief with a few sessions. She had complete healing of all ulcers, leav ing white polygonal scars with peripheral hyper-pigmented macules. New lesions ceased to develop and she had not recurrence for the following sixteen months.

Fig. 1 A 26-year-old female with livedoid vasculopathy before (A, B, C) and after 12 sessions of hyperbaric oxygen therapy (Revitalair 430 ≈100%O2) (D, E, F) 


LV is the cutaneous manifestation of several diseases that lead to non-inflammatory thrombosis of dermal vessels. Reduced fibrinolytic activity in the blood of these patients, with reduced release of tissue plasminogen activator from vessel walls, leads to demonstrated increased aggrega tion activity1,2.

A variety of treatments with varying degrees of success have been used to treat LV. The efficacy of anticoagulants supports the main proposed pathogenic mechanism for LV of an occlusive vasculopathy. HBOT was described as treatment for LV in few cases, gener ally in combination with other drugs to be able to achieve remission4,12-14.

It has been shown that HBOT is able to increase the release of various fibrinolytic molecules from endothelial cells15,16. In vitro, in an ischaemia-reperfusion model using cultured endothelial cells, HBO stimulated the secretion of fibrinolytic factors including urokinase, plasminogen activator (t-PA) and plasminogen activator inhibitor type 1 (PAI-1)15.

Although clinical use of HBOT was defined at more than 1.4 ATA8, some authors suggest higher pressure hyperbaric for wound treatment7.

Actually, there is a rapid emergence of more acces sible, safer and portable hyperbaric chamber working at lower pressures17. Low pressure hyperbaric oxygen therapy is effective and proposed to neurological diseases but right now it is used in some refractory wounds17. Physiological benefits like angiogenesis, collagen synthesis and endothelial anti-inflammation are achieved at a pressure as safe as 1.45 ATA9-11. HBOT at 1.45 ATA generates a physical dissolution of oxygen in plasma and tissue fluids 10 times higher than that achieved by breathing room air at norm baric pressure17. Thus, HBOT uses hyperbaric chambers that work at 1. 45 ATA are effective in tissue oxygen ation. It creates a high oxygen gradient across the wound site and counteracts the damaging effect of tissue ischaemia6,17.

Authors had first used higher pressure HBOT for the management of LV with rapid healing of ulcers and sig nificant reduction in pain. As far as we are aware, this is the first report of low-pressure HBOT for LV treatment. We report pain relief with a few sessions and complete heal ing after 12 sessions of HBOT at 1.45 ATA. More studies and clinical cases series are necessary to demonstrate if low-pressure HBOT is effective for LV treatment and quality life improvement in these patients.


1. Criado PR, Rivitti EA, Sotto MN, et al. Livedoid vasculopa thy: an intringuing cutaneous disease. An Bras Dermatol 2011; 86: 961-77. [ Links ]

2. Miqueri MJ, Cingolani S, Pane L, et al. Vasculopatía live doide. Dermatol Argent 2018; 24: 121-7. [ Links ]

3. Polo Gascón MR, de Carvalho JF, de Souza Espinel DP, Barros AM, Alavi A, Criado PR. Quality-of-life impair ment in patients with livedoid vasculopathy. J Am Acad Dermatol 2014; 71: 1024-6. [ Links ]

4. Juan WH, Chan YS, Lee JC, Yang LC, Hong HS, Yang CH. Livedoid vasculopathy: long-term follow-up results following hyperbaric oxygen therapy. Br J Dermatol 2006; 154: 251-5. [ Links ]

5. Micieli R, Alavi A. Treatment for Livedoid Vasculopathy: A Systematic Review. JAMA Dermatol 2018; 154: 193-202. [ Links ]

6. El Oumri AA, Badi H, Khaloufi S, et al. Hyperbaric Oxygen Therapy: Focus. EMOJ 2018; 6: 15-20. [ Links ]

7. Mathieu D, Marroni A, Kot J. Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving Hyperb Med 2017; 47: 24-32. [ Links ]

8. Weaver LK and Undersea and Hyperbaric Medical Society. Hyperbaric Oxygen Therapy Indications: 13th Edition 2014, Florida, USA: Best Publishing Company, Florida Durham. [ Links ]

9. Hopf HW, Gibson JJ, Angeles AP, et al. Hyperoxia and angiogenesis. Wound Repair Regen 2005; 13: 558-64. [ Links ]

10. Sheikh AY, Gibson JJ, Rollins MD, Hopf HW, Hussain Z, Hunt TK. Effect of hyperoxia on vascular endothelial growth factor levels in a wound model. Arch Surg 2000; 135: 1293-97. [ Links ]

11. Kendall A, Whatmore JL, Harries LW, et al. Different oxy gen treatment pressures alter inflammatory gene expres sion in human endothelial cells. Undersea Hyperb Med 2013; 40: 115-23. [ Links ]

12. Yang CH, Ho HC, Chan YS, Liou LB, Hong HS, Yang LC. Intractable livedoid vasculopathy successfully treated with hyperbaric oxygen. Br J Dermatol 2003; 149: 647-52. [ Links ]

13. Ray R, Sharma A, Vasudevan B, Sridhar J, Deo R, Mo hanty CS. Livedoid Vasculopathy with Hyperhomocystein emia Responding to Hyperbaric Oxygen Therapy. Indian J Dermatol 2015; 60: 524. [ Links ]

14. Weinschenker Bollmann P, Kazumi Shimada A, Schwery Michalany N, De Araújo Burgos Manhani AR, Del Giglio A. Livedoid vasculopathy: fast involution after anticoagulant and hyperbaric oxygen therapy. Einstein (São Paulo) 2011; 9: 212-5. [ Links ]

15. Tjärnström J, Holmdahl L, Falk P, Falkenberg M, Arnell P, Risberg B. Effects of hyperbaric oxygen on expression of fibrinolytic factors of human endothelium in a simulated ischaemia/reperfusion situation. Scand J Clin Lab Invest 2001; 61: 539-45. [ Links ]

16. Yamami N, Shimaya K, Sera AM, et al. Alterations of fibrinolytic activity in human during and after hyperbaric oxygen exposure. Appl Human Sci 1996; 15: 239-42. [ Links ]

17. Cannellotto M, Romero-Feris D, Pascuccio MM, Jordá-Vargas L. Aplicaciones médicas de las cámaras de oxi genación hiperbárica de nueva generación. Asoc Med Arg 2018; 131:12-20. [ Links ]

Received: June 01, 2021; Accepted: March 04, 2022

*Postal address: Fabrizio Verdini, Ceretti 3320, 1429 Buenos Aires, Argentina e-mail:

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