A Double Diagnosis Behind Chronic Ulcers: Livedoid Vasculopathy With Acroangiodermatitis in an Elderly Woman

Chronic leg ulcers are a significant source of morbidity in elderly patients, particularly those with multiple comorbidities. The most common etiologies are vascular, including chronic venous insufficiency, peripheral arterial disease, and diabetic neuropathy. However, ulcers that are non-healing and refractory to standard treatment may reflect rarer underlying pathologies, warranting comprehensive reassessment. We report the case of an 87-year-old woman presenting with recurrent, painful, bilateral lower-limb ulcers, persisting for 18 months on the right leg and 10 months on the left. Her medical history was notable for chronic kidney disease, heart failure, and a previous myocardial infarction managed with dual coronary artery stenting. The ulcers had been treated in the community with dressings and multiple courses of oral antibiotics, with recurrent hospital admissions for secondary infection. She re-presented to the emergency department with worsening ulceration, rigours, raised inflammatory markers, and clinical features of infection. Initial management included intravenous antibiotics, analgesia, specialist wound care, and tissue viability input. Vascular surgical assessment confirmed adequate arterial supply, and there was no clinical evidence of peripheral neuropathy. Despite optimal conventional management, wound healing remained poor, prompting consideration of alternative diagnoses, including pyoderma gangrenosum, vasculitic ulceration, and cutaneous malignancy. Extensive autoimmune and vasculitis screening was negative. Punch biopsy demonstrated a vasculopathic pattern with increased vascular proliferation, fibrinoid necrosis of small vessels, diffuse neutrophilic infiltrates, and fibrin deposition extending into the deeper dermis. These findings were consistent with coexisting livedoid vasculopathy (LV) and acroangiodermatitis (AAD) secondary to chronic venous stasis, excluding other differentials. This combination is rare, particularly in advanced age. Treatment included topical clobetasol 0.05% cream to peri-wound skin, topical potassium permanganate 0.01% to infected areas, oral dapsone 50 mg twice daily for 3 months, and clopidogrel 75 mg daily, alongside compression therapy and multidisciplinary wound care. Marked clinical improvement was observed within two weeks. This case highlights the diagnostic complexity of chronic leg ulcers, the importance of maintaining a broad differential diagnosis, and the pivotal role of skin biopsy and multidisciplinary collaboration in guiding effective, individualised management.