Buerger's disease manifesting nodular erythema with livedo reticularis

We report a patient with Buerger's disease (BD) who showed painful nodular erythema with livedo reticularis as an initial symptom. The patient developed this cutaneous manifestation in both lower extremities, and a skin biopsy demonstrated perivascular infiltration of mononuclear cells in the border zone between the dermis and subcutaneous tissue. Both nodular erythema and livedo reticularis were successfully treated with oral prednisolone, but both feet developed necrosis with ulcerations and had to be amputated 1.5 years later because of acute gangrene. Histopathology of the amputated tissue showed acute inflammation and multiple thrombi with recanalization in the posterior tibial arteries, leading to a diagnosis of BD. This disease should be considered as a possible diagnosis in refractory patients with nodular erythema and livedo reticularis, particularly when ulcerations and necrosis rapidly worsen.