PMC9809396_01
Initial presentation. Slowly progressive blanching livedo reticularis.
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A 54-year-old woman with a long-standing history of well-controlled psoriatic arthritis on adalimumab and methotrexate presented with a five-month duration of a slowly progressive blanching livedo reticularis that started on bilateral dorsal feet and toes and extended to the calves (Figure 1).
Hematoxylin-eosin (original magnification x40). Histologic examination of an excisional biopsy revealed medium-sized vessel arteritis in the upper subcutis showing lymphocytes and few neutrophils within the vessel wall with incipient necrotizing features and plumped endothelium.
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An incisional full-thickness skin biopsy of the right calf that included an unaffected center and adjacent reticulated area revealed a leukocytoclastic and necrotizing medium and small muscular artery vasculitis (Figure 2).
Necrotic toes.
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Still, she developed worsening necrosis of the affected toes of her right foot (Figure 3) and marked improvement in pain and dysesthesia.
Livedo racemosa of the first toe. Note auto-amputated second to fifth toes of the right foot.
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She returned to the clinic with painful livedo reticularis and livedo racemosa of the second and third digits of the left foot, the first digit of the right foot (Figure 4), and the joint lines of the digits of the bilateral hands.