30-50ml/min, while use is contraindicated in patients with creatinine clearance <30ml/min.3 Rivaroxaban is metabolized by cytochrome P450 3A4 and is a substrate for the p-glycoprotein transporter, which are both inhibited by systemic azole antifungals.2 Dermatologists should be aware of rivaroxaban in terms of its drug interactions, but also as a potential dermatologic therapy.
In dermatology, rivaroxaban has recently been shown to be effective in the treatment of livedoid vasculopathy (LV), with its success suggesting a role for NOACs in the treatment of nonvasculitic cutaneous vasculopathy in general. Prior to the advent of NOACs, a 2012 review of LV treatment amongst dermatologists indicated that most case series utilized antiplatelet agents as first-line therapy.4 However, recently, multiple case reports have demonstrated successful treatment of LV with rivaroxaban, dosed at 10mg or 20mg once daily or 10mg bid.5-10 In many cases, these patients had failed initial treatment with alternative immunosuppressive, antiplatelet, or anticoagulant therapies.5-7,10
In the case presented herein, an unremarkable laboratory and imaging work-up coupled with a biopsy demonstrating dermal fibrin thrombi without evidence of vasculitis was concerning for cutaneous vasculopathy. It is unknown if over time her lesions would have progressed to become more chronic and ulcerative, as is commonly seen in the “atrophie blanche†lesions of LV. Regardless, we observed a rapid, complete response to rivaroxaban, demonstrating its potential utility in patients with idiopathic cutaneous vasculopathy. Furthermore, this case indicates that rivaroxaban therapy remains useful in cutaneous vasculopathy even in the absence of laboratory evidence of hypercoagulability. Most importantly, this case suggests that early intervention with a NOAC in cutaneous vasculopathy can eliminate the need for significant pain medication as well as prevent progression to ulceration and atrophy. Dermatologists should be aware of the potential therapeutic use of NOACs in patients with cutaneous vasculopathy.
In dermatology, rivaroxaban has recently been shown to be effective in the treatment of livedoid vasculopathy (LV), with its success suggesting a role for NOACs in the treatment of nonvasculitic cutaneous vasculopathy in general. Prior to the advent of NOACs, a 2012 review of LV treatment amongst dermatologists indicated that most case series utilized antiplatelet agents as first-line therapy.4 However, recently, multiple case reports have demonstrated successful treatment of LV with rivaroxaban, dosed at 10mg or 20mg once daily or 10mg bid.5-10 In many cases, these patients had failed initial treatment with alternative immunosuppressive, antiplatelet, or anticoagulant therapies.5-7,10
In the case presented herein, an unremarkable laboratory and imaging work-up coupled with a biopsy demonstrating dermal fibrin thrombi without evidence of vasculitis was concerning for cutaneous vasculopathy. It is unknown if over time her lesions would have progressed to become more chronic and ulcerative, as is commonly seen in the “atrophie blanche†lesions of LV. Regardless, we observed a rapid, complete response to rivaroxaban, demonstrating its potential utility in patients with idiopathic cutaneous vasculopathy. Furthermore, this case indicates that rivaroxaban therapy remains useful in cutaneous vasculopathy even in the absence of laboratory evidence of hypercoagulability. Most importantly, this case suggests that early intervention with a NOAC in cutaneous vasculopathy can eliminate the need for significant pain medication as well as prevent progression to ulceration and atrophy. Dermatologists should be aware of the potential therapeutic use of NOACs in patients with cutaneous vasculopathy.
DISCLOSURES
The authors have no conflicts of interest to disclose.
REFERENCES
1. Llamas-Velasco M, Alegria V, Santos-Briz A, et al. Occlusive nonvasculitic vasculopathy. Am J Dermatopathol. 2017;39:637-662.
2. Plovanich M, Mostaghimi A. Novel oral anticoagulants: what dermatologists need to know. J Am Acad Dermatol. 2015;72(3):535-540. 3. Poulsen BK, Grove EL, Husted SE. New oral anticoagulants. Drugs. 2012;72(13):1739-1743.
4. Gonzalez-Santiago TM, Davis MDP. Update of management of connective tissue diseases: livedoid vasculopathy. Dermatol Ther. 2012;25:183-194.
5. Marques GF, Criado PR, Morita T, et al. The management of livedoid vasculopathy focused on direct oral anticoagulants (DOACs): four case reports successfully treated with rivaroxaban. Int J Dermatol. 2018;57:9.
6. Miguel D, Elsner P, Goetze S. Chronic leg ulcerations associated with livedoid vasculopathy successfully treated with rivaroxaban. Clin Exp Dermatol. 2019.
7. Evans JM, Jensen JD, Sami N. Successful treatment of livedoid vasculopathy with rivaroxaban. JAAD Case Rep. 2015;1:340-341.
8. Lee JM, Kim IH. Case series of recalcitrant livedoid vasculopathy treated with rivaroxaban. Clin Exp Dermatol. 2016;41:559-561.
9. Kerk N, Drabik A, Luger TA, et al. Rivaroxaban prevents painful cutaneous infarctions in livedoid vasculopathy. Br J Dermatol. 2013;168:898-899.
10. Winchester DS, Drage LA, Davis MD. Response of livedoid vasculopathy to rivaroxaban. Br J Dermatol. 2015;172:1148-1150.
2. Plovanich M, Mostaghimi A. Novel oral anticoagulants: what dermatologists need to know. J Am Acad Dermatol. 2015;72(3):535-540. 3. Poulsen BK, Grove EL, Husted SE. New oral anticoagulants. Drugs. 2012;72(13):1739-1743.
4. Gonzalez-Santiago TM, Davis MDP. Update of management of connective tissue diseases: livedoid vasculopathy. Dermatol Ther. 2012;25:183-194.
5. Marques GF, Criado PR, Morita T, et al. The management of livedoid vasculopathy focused on direct oral anticoagulants (DOACs): four case reports successfully treated with rivaroxaban. Int J Dermatol. 2018;57:9.
6. Miguel D, Elsner P, Goetze S. Chronic leg ulcerations associated with livedoid vasculopathy successfully treated with rivaroxaban. Clin Exp Dermatol. 2019.
7. Evans JM, Jensen JD, Sami N. Successful treatment of livedoid vasculopathy with rivaroxaban. JAAD Case Rep. 2015;1:340-341.
8. Lee JM, Kim IH. Case series of recalcitrant livedoid vasculopathy treated with rivaroxaban. Clin Exp Dermatol. 2016;41:559-561.
9. Kerk N, Drabik A, Luger TA, et al. Rivaroxaban prevents painful cutaneous infarctions in livedoid vasculopathy. Br J Dermatol. 2013;168:898-899.
10. Winchester DS, Drage LA, Davis MD. Response of livedoid vasculopathy to rivaroxaban. Br J Dermatol. 2015;172:1148-1150.
