livedoid vasculopathy ( lv ) is a rare cutaneous disease which manifests mainly as recurrent leg ulcers . these ulcers heal with atrophic , porcelain white scars called atrophie blanche , which is an alternative named used for the disease . inflammation , autoimmunity and hypercoagulability are the main pathogenetic factors with the latter being the most predominant among them . the recurrent nature and controversial pathogenesis makes this disorder a very challenging one to treat . we herein report a case of lv associated with hyperhomocysteinemia which responded well to hyperbaric oxygen therapy ( hbot ) , thus providing a novel , efficient and safe option for management . this 30-year - old male presented with complaints of multiple ulcers over both legs of 6 years duration . the patient gave history of initially developing few ulcers on the left foot after prolonged wearing of boots for duration of 7 days ( 18 hours / day ) . he progressively developed similar multiple ulcers over both lower legs and dorsum of feet over a duration of 2 weeks . they were associated with moderate intensity pain and would increase on walking or running and reduce with rest . the ulcers had a waxing and waning course and would generally heal with course of antibiotics and rest . dermatological examination revealed multiple ulcers distributed in a reticular pattern over medial and lateral aspects of both lower legs , extensor aspect of both ankles and dorsum of both feet [ figure 1 ] . multiple atrophic porcelain white scars were also present in the interspersed and adjoining regions along with post inflammatory hyperpigmentation . ulcers had well - defined margins , sloping edges and the floor had granulation tissue with no discharge [ figure 2 ] . distribution of ulcers on : ( a ) the medial aspect of both legs and feet . ( b ) lateral aspect of dorsum of left feet and leg close up images revealing ( a ) livedoid ulcers on leg long with atrophie blanche and ( b ) reticulate pattern of ulcers on dorsum of foot investigations revealed normal hemogram , liver and renal function tests . antinuclear antibodies , hepatitis b surface antigen ( hbsag ) , anti - hepatitis c , vdrl and hiv testing were all negative . antineutrophil cytoplasmic antibodies ( anca ) , antiphospholipid antibodies ( apla ) , protein c and s , antithrombin iii , factor v leiden , prothrombin gene mutation and methylene tetrahydrofolate reductase ( mthfr ) gene polymorphisms were all negative . a skin biopsy from the ulcers revealed ulcerated epidermis with intervening orthokeratotic epidermis , mild acanthosis and spongiosis . most of the vessels showed thickened walls with fibrin deposition and thrombus formation [ figure 3 ] . with these features a diagnosis of lv with associated histopathology revealing extensive fibrin deposition and thrombus formation in the dermal vessels with absent inflammation [ hematoxylin and eosin stain 10 ] he was prescribed oral prednisolone 60 mg along with , pentoxyphylline , low - dose aspirin , folic acid and local cleaning of ulcers with normal saline . patient was given a course of hbot for the ulcers along with continuation of pentoxyphylline , aspirin and folic acid . the patient was administered hbot in a multiplace chamber at pressure of 2.5 atmospheres for 90 min daily , 6 days a week . at the end of 10 sittings of hbot , ulcers in the feet and ankles showed signs of healing in the form of appearance of granulation tissue in the base , shrinking margins , reduced inflammation and reduced tenderness . by the end of 15 sittings , the patient was followed up for 1 year during which no recurrence of ulcers was noted . lv is presently described as a condition manifesting as recurrent leg ulcers with thrombosis of the microcirculation as the main pathogenesis . the important procoagulant causes include hyperhomocysteinemia , proteins c and s deficiency , factor v leiden mutation , prothrombin gene mutation , antithrombin iii deficiency and antiphospholipid antibody syndrome . the genetic causes of homocystenemia are mainly due to enzyme defects such as cystathione--synthase , methylenetetrahydrofolate reductase and methionine synthase deficiencies . acquired causes include nutritional deficiencies , renal failure , use of folic acid and vitamin b6 antagonists , cardiovascular diseases and peripheral arterial occlusive disease . hbot is a recognized modality of treatment of various problem wounds and non - healing ulcers due to various etiologies . the non - healing ulcers form the single largest group of indications for which hbot is being administered . this group includes various indications like diabetic foot ulcers , arterial insufficiency ulcers , ulcers due to venous stasis , decubitus ulcers and fungal infections . these disorders have a common pathology in having ischemia and infection as the most common causes of non - healing . hyperbaric oxygen acts by delivering 100% oxygen at high pressures ( 2 - 3 atmospheres pressure ) wherein oxygen dissolves 20 times more in plasma and tissue fluids than at room air pressure . therefore , a high oxygen gradient is produced across the wound site negating the damaging effects of tissue ischemia . it also increases the release of fibrinolytics from endothelial cells , promotes angiogenesis of ischemic tissue and facilitates neovascularization , thereby accelerating healing in lv . other proposed mechanisms include increased collagen formation , inhibition of bacterial overgrowth and reduced tissue reperfusion injury . contraindications for hbot include previous chest or ear surgery , pregnancy , seizures , malignancy , pneumothorax , emphysema and upper respiratory tract infections . so chest x - ray , pulmonary function tests , and eardrum examination are a must before starting therapy . severe adverse effects are very rare and middle ear barotraumas are the most common reported adverse effects . our patient had lv associated with homocystenemia and he showed very good response to hbot . lv itself has been very rarely reported from india and few reports globally have reported use of hbot for lv . hbot therapy is therefore a novel , relatively cost - effective , opd treatment option in lv . it is probably not only a means of therapy for healing the ulcers , but also to get longer recurrence free periods . hyperbaric oxygen therapy is a novel , safe and beneficial therapy for livedoid vasculopathyhyperbaric oxygen therapy can not only help in healing ulcers , it can also help in prolonging remission periods in such cases . hyperbaric oxygen therapy is a novel , safe and beneficial therapy for livedoid vasculopathy hyperbaric oxygen therapy can not only help in healing ulcers , it can also help in prolonging remission periods in such cases .
a 30-year - old male presented to the dermatology department with complaints of multiple ulcers over both legs of 6 years duration . 
 the ulcers had a waxing and waning course with present exacerbation of lesions since 1 month . 
 dermatological examination revealed multiple ulcers distributed in a reticular pattern over medial and lateral aspects of both lower legs , extensor aspect of both ankles and dorsum of both feet . 
 multiple interspersed atrophic porcelain white scars were also present 
 . investigations revealed raised serum homocysteine levels . 
 a skin biopsy from the ulcers showed features of livedoid vasculopathy . following recurrence of lesions after oral corticosteroid therapy , the patient 
 was given a course of hyperbaric oxygen therapy for the ulcers to which he responded very well . 
 this case is being presented for the novel option of hyperbaric oxygen therapy in livedoid vasculopathy , which by itself is rarely reported in this part of the world .