Nicolau livedoid dermatitis occurring after sclerotherapy

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A 53-year-old woman presented with a lesion within the left popliteal fossa 2 weeks following varicose vein sclerotherapy. Two days following the sclerotherapy (polidocanol 1%), she complained of pain within the injection site that did not respond to anti-inflammatory or analgesic medications. Clinical examination illustrated a livedoid lesion with geographic margins and a necrotic center at the site of injection of polidocanol (Panel). A duplex ultrasound documented occlusion of a small saphenous vein (SSV) tributary and incompetence within the proximal portion of the SSV proper.

A diagnosis of Nicolau livedoid dermatitis (NLD) was rendered. Treatment included low-molecular weight heparin (LMWH; enoxaparin 40 mg/day), a class IV topical corticosteroid (clobetasol propionate), and a gradient compression stocking. The pain abated over several days and 10 days later the lesion resolved.

NLD is a rare cutaneous reaction at subcutaneous or intramuscular injection sites characterized by intense pain followed by a violaceous livedoid plaque that may evolve to skin necrosis. It often occurs in weak areas (e.g. inguinal folds, popliteal fossa) and is due to direct arterial embolism, ischemia after perivascular compression of the injected product, and/or reflex arterial vasospasm due to para-neural or para-arterial injection. The latter mechanism was thought to underlie the pathogenesis of NLD in our subject. Until recently, it has been rarely reported with varicose vein sclerotherapy.^1–4 Treatment of NLD is not well specified. Usual therapy relies on anticoagulants and prednisone. ² We used LWMH and a local potent corticosteroid, not prednisone as is the usual practice,^1–4 with an excellent result. Thus, an appropriate topical glucocorticoid agent could replace systemic steroid therapy when treating a focal lesion of NLD.