Lipodermatosclerosis: a postphlebitic syndrome

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A 30-year-old businessman, weighing 94 kg, presented with pigmentation and skin changes extending from the calf to the dorsum of the left foot. One year ago, the patient noticed erythema around the medial malleolus and edema of the ankle, following trauma while starting a bike. The patient was afebrile during the event. He gave no history suggestive of muscle weakness, cramping calf pains at rest, intermittent claudication while walking, paresthesia, or increased sensitivity to cold. No history suggestive of systemic involvement was obtained.On examination, the affected part showed pigmentary color changes varying from brown to bluish black (diffuse around the ankle and mottled towards the knee). The overlying skin was warm, indurated, brawny, and stony hard. Along with patchy hair loss, there was a painless decrease in the mobility of the left ankle. The circumference of the left calf and ankle measured approximately 2.5 cm less than the corresponding right side. The skin on the thigh above was hypertrophied and pachydermatous. There was no evidence of varicose veins.The blood count, urine analysis, erythrocyte sedimentation rate, bleeding, clotting, and prothrombin time were all within normal limits. Blood sugar levels were moderately elevated. Antinuclear-antibodies were absent.Histopathology of the skin biopsy showed uniform thinning of the epidermis, with focal areas of increased pigmentation in the stratum basale. A sparse perivascular lymphocytic infiltrate was seen around the superficial and deep vessels of the reticular dermis. The collagen bundles were closely packed, homogeneous, thickened, and deeply stained. The subcutaneous tissue was replaced with collagen fibers, thus resembling a scleroderma-like picture.Color Doppler showed evidence of segmental thrombosis in the left posterior tibial and peroneal veins.Before the dermatologic referral, the patient had been treated with intravenous heparin followed by tablet aspirin. We advised dietary restrictions for weight reduction and control of diabetes. In addition, we recommended vitamin supplements and compression stockings. The patient was taught limb care with special emphasis on leg elevation and exercise (to hasten the development of collaterals).

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