Table I. General characteristics of 24 patients withlivedoid vasculopathy

Gender N (%)

Female 14 (58.3)Male 10 (41.7)

Age, y# 30 3 (12.5)31-45 9 (37.5)$46 12 (50)

EducationOnly a fundamental education 7 (29.2)Completed high school 8 (33.3)University 9 (37.5)

Disease duration, y1-5 7 (29.2)6-10 5 (20.8)11-15 8 (33.3)[15 4 (16.7)

Family history of thrombosisYes 13 (54.2)No 11 (45.8)

Family history of varicesYes 16 (66.7)No 8 (33.3)

J AM ACAD DERMATOL

NOVEMBER 20141024 Letters

Quality-of-life impairment in patients withlivedoid vasculopathy

To the Editor: Livedoid vasculopathy is a rarechronic noninflammatory thrombotic disease clini-cally characterized by purple, punctate, or reticularpainful macules of lower extremities, particularly onthe ankle and back of the foot that eventually mayulcerate and often followed by a white atrophic scarcalled ‘‘atrophie blanche.’’1 Active disease wasdefined as the presence of lesions such as purpura,bruises, and painful ulcers and inactive diseasedefined as the presence of scars, hyperpigmentation,and atrophie blanche.

Coagulopathies and defects in fibrinolysis play animportant role in the pathogenesis.2 The aim ofthis study was to evaluate the impact of livedoidvasculopathy on patient quality of life and to identifythe most affected areas.

We conducted a cross-sectional study on 24patients (12 with active disease) seen in the derma-tology clinic. All patients signed an informed consentform approved by the local ethics committee. Allpatients had a biopsy specimen confirming livedoidvasculopathy and completed 2 questionnaires: theDermatology Life Quality Index (DLQI)eBrazilianVersion 13 and the 36-Item Short-Form HealthSurvey.3 Both tools have been validated. Thedemographic data are listed in Table I.

The mean total DLQI score was 11.37 (SD 9.2).The areas that showed greater impairment of qualityof life were symptoms and feelings, activities of dailyliving, and work/school.

The areas with greater quality-of-life impairmentwere physical (44.79 6 47.19) and pain (53.13 630.49). Functional capacity (66.88 6 31.61) andmental health (63.67 6 30.67) areas were lessaffected.

Patients with active disease reported a greaterimpact on their quality of life. This was particularlyevident in the areas of symptoms and feelings (4.08,61.78), activities of daily living (4.00 6 2.41), leisure(4.16 6 2.16), physical (8.75 6 23:56), emotional(24.65 6 34.39), and social aspects (29.94 6 28.14)when compared with patients with inactive livedoidvasculopathy, as shown in Table II.

Patients with livedoid vasculopathy had signifi-cantly impaired quality of life that occurred primar-ily in the psychological, physical, and socialdomains, particularly with disease activity. Theanalysis of the DLQIeBrazilian Version 13 and 36-Item Short-Form Health Survey scores demon-strated that livedoid vasculopathy is a disease thataffects patient quality of life, particularly in activestage.

Themean totalDLQI scorewas11.37, and increasedto 17.83 when the disease was active. This is a highscore comparedwith other chronic dermatoses such asleprosy, psoriasis, atopic dermatitis, and vitiligo,whereaverage scores of 4.0 to 13.5 were observed (Fig 1).4

DLQI scores for common skin diseases were reportedas 7.5 for acne, 8.3 for alopecia, and 6.1 for Hailey-Hailey disease, significantly lower than our results inlivedoid vasculopathy.5

Patients with skin disease often experiencesignificant psychological and social distress that mayalso impact their occupational lives. Dermatologistsshould recognize the impact of the disease onquality of life and map out their management planaccordingly.

The results of this study demonstrate that livedoidvasculopathy has great impact on activities of dailyliving measured by 36-Item Short-Form HealthSurvey and DLQI. The most important factors relatedto quality of life were extent of physical involvementand the presence of pain.

The limitation of our study is the small samplesize. Additional studies with larger sample size arerequired. Although the findings of the currentstudy are internally valid, they may not generalizeto all patients. Our findings have importantimplications on the treatment plan to considerthe pain management and the extent of skininvolvement.

Fig 1. Dermatology Life Quality Index score in different skin diseases.

Table II. Dermatology Life Quality Index and 36-Item Short-Form Health Survey mean scores of 24 patientswith livedoid vasculopathy divided into 2 groups (active and inactive)

Activity (n = 12) Remission (n = 12) P

DLQI total score 17.83 (66.73) 4.83 (66.23) .001DLQI domain scoresSymptoms/feelings 4.08 (61.78) 1.50 (62.06) .002Daily activities 4.00 (62.41) 0.91 (61.88) .001Leisure 4.16 (62.12) 0.41 (60.99) .000Work/school 2.91 (60.28) 1.41 (60.99) .000Interpersonal relationships 2.33 (62.14) 0.58 (61.73) .008Treatment 0.33 (60.88) 0.00 (60.00) .149

SF-36 domain scoresFunctional capacity 41.25 (620.46) 92.92 (611.17) .000Physical features 8.75 (623.56) 75.00 (641.28) .000Pain 35.5 (626.60) 63.75 (630.84) .025General health state 47.04 (627.55) 76.71 (618.55) .006Vitality 37.91 (624.81) 76.66 (626.65) .007Social aspects 29.94 (628.14) 86.45 (622.27) .001Emotional aspects 24.65 (634.39) 83.31 (626.61) .001Mental health 33.83 (628.05) 78.91 (616.47) .003

DLQI, Dermatology Life Quality Index; SF-36, 36-Item Short-Form Health Survey.

J AM ACAD DERMATOL

VOLUME 71, NUMBER 5Letters 1025

Maria Rita Polo Gasc�on, MD,a Joz�elio Freire deCarvalho, MD, PhD,b Danielle Priscila de SouzaEspinel, MD,a Alessandra Moraes Barros, MD,a

Afsaneh Alavi, MD,c and Paulo Ricardo Criado,MD, PhDa

Department of Dermatology, University of S~aoPaulo, Brazila; Rheumatology Division, AliancaMedical Center, Salvador, Bahia, Brazilb; andDepartment of Dermatology, University ofToronto, Ontario, Canadac

Funding sources: None.

Conflicts of interest: None declared.

Correspondence to: Afsaneh Alavi, MD, WoundCare Center, Women’s College Hospital (mainbuilding), 76 Grenville St, 10th Floor, Toronto,ON M5S 1B2, Canada

E-mail: afsaneh.alavi@utoronto.ca

REFERENCES

1. Criado PR, Rivitti EA, Sotto MN, Valente NY, Aoki V, Carvalho JF,

Vascocellos C. Livedoid vasculopathy: an intriguing cutaneous

disease. An Bras Dermatol 2011;86:961-77.

J AM ACAD DERMATOL

NOVEMBER 20141026 Letters

2. Di Giacomo TB, Hussein TP, Souza DG, Criado PR. Frequency of

thrombophilia determinant factors in patients with livedoid

vasculopathy and treatment with anti coagulant drugsea

prospective study. J Eur Acad Dermatol Venereol 2010;24:

1340-6.

3. Taborda ML, Teixeira KAM, Welter EQ, Lisboa AP, Weber MB.

Evaluation of the quality of life and psychological distress

of patients with different dermatoses in a dermatology

referral center in southern Brazil. An BrasDermatol 2010;85:52-6.

4. Hong J, Koo B, Koo J. The psychosocial and occupational

impact of chronic skin disease. Dermatol Ther 2008;21:54-9.

5. Lewis V, Finlay AY. 10 Years’ experience of the Dermatology

Life Quality Index (DLQI). J Investig Dermatol Symp Proc 2004;

9:169-80.

http://dx.doi.org/10.1016/j.jaad.2014.06.030

Patient-reported outcomes ofelectrodessication and curettage for treatmentof nonmelanoma skin cancer

To the Editor:We have shown that electrodessicationand curettage (ED&C) cures most ([95%) basal celland cutaneous squamous cell carcinomas (nonme-lanoma skin cancers [NMSCs]) for which it is used,1

Table I. Characteristics of study sample of patients with n

Characteristics

Patient characteristicsMedian age, y (IQR)Male genderAnnual income # $30,000History of NMSCNo. of NMSCs at presentation, mean6 SD

Tumor characteristicsHistologic type, basal cell carcinomaInvasiveHistopathological risk factor for recurrence1

Median tumor diameter, mm (IQR)Tumor present on face, scalp, or neck

Care characteristicsTreatment site, VA Medical CenterTraining level of treating clinician, attending physicianMedian no. of annual dermatology visits over follow-upperiod (IQR)

No. of cycles of ED&C performed, mean6 SDClosure typeSecondary intentionPrimary linear closureUse of flap or graftOther

Data were missing for the ED&C group/excision or Mohs group for the

7/80, health status 12/53, tumor diameter 52/39, training level of clinicia

ED&C, Electrodessication and curettage; IQR, interquartile range; NA, not

Veterans Affairs.

*Comparison of ED&C group with excision/Mohs group.

but skin-related quality of life after ED&C does notimprove as much as after excision or Mohs micro-graphic surgery.2 Our goal was to determine otherpatient-reported outcomes after treatment of NMSCwith ED&C.

We studied all patients with primary NMSCstreated with ED&C, excision, or Mohs micrographicsurgery in 1999 through 2000 at a university hospitalor its affiliated Department of Veterans Affairs clinic,and who responded to a survey before treatment.The final sample consisted of 149 patients treatedwith ED&C and 568 treated with excision or Mohsmicrographic surgery.

Three months after treatment, we used anadapted version of the 18-item Patient SatisfactionQuestionnaire to measure satisfaction with care,including its technical quality, interpersonal manner,communication, financial aspects, time with clini-cian, and accessibility.3 Responses vary from 1 to 5,with higher scores indicating greater satisfaction.One year after treatment, we used global itemsto measure patients’ description of cosmetic

onmelanoma skin cancer

Treatment group

ED&C (N = 149)

Excision or Mohs

micrographic

surgery (n = 568) P*

66 (54-76) 69 (56-77) .0879% 76% .4249% 53% .3043% 48% .30

1.3 6 0.6 1.3 6 0.7 .95

80% 73% .1044% 82% \.0016% 26% \.001

8 (5-12) 8 (5-12) .6328% 79% \.001

44% 51% .1252% 69% \.001

1.8 (1.0-2.8) 1.7 (0.6-3.1) .18

2.96 .36 NA NA

100% 11% \.0010% 68%0% 19%0% 2%

following number of patients or tumors: income 13/37, skin type

n 11/8, cycles of ED&C 32/-, and closure type 7/33.

applicable; NMSC, nonmelanoma skin cancer; VA, Department of