Refractory livedoid vasculopathy successfully treated with CHAP therapy and punch grafts: two case reports

Livedoid vasculopathy (LV) is a chronic thrombotic microangiopathy characterized by painful ulcerations that significantly impair quality of life. Management of refractory LV remains challenging as conventional therapies have limited efficacy. We report two female patients with chronic, painful ulcers unresponsive to multiple intravenous immunoglobulin cycles who achieved complete ulcer healing and rapid pain resolution following a combined regimen of CHAP therapy, comprising nifedipine, hydroxychloroquine, aspirin and pentoxifylline, compression bandaging and punch grafts. Patient 1 is a 60-year-old woman who is a current smoker with hypothyroidism. She showed complete ulcer closure within 28 days and full analgesia by day 21, maintaining remission at 1-year follow-up. Patient 2 is a 55-year-old woman with diabetes and rheumatoid arthritis who achieved near-complete healing within 9 weeks, with rapid pain relief and no adverse events. This novel multimodal approach addresses key aspects of LV pathogenesis, including impaired vasodilation, platelet aggregation and immune dysregulation. It is complemented by the analgesic and reparative benefits of punch grafting. Our findings suggest that CHAP therapy combined with punch grafts may represent a safe and effective treatment option for patients with refractory LV. This therapy merits further evaluation in controlled studies.