Skip to main content
Top
Published in: American Journal of Clinical Dermatology 1/2023

29-10-2022 | Vasculitis | Therapy in Practice

Cutaneous Small Vessel Vasculitis: A Practical Guide to Diagnosis and Management

Author: Robert G. Micheletti

Published in: American Journal of Clinical Dermatology | Issue 1/2023

Login to get access

Abstract

Cutaneous vasculitis may be a cutaneous manifestation of systemic vasculitis, a skin-limited variant of systemic vasculitis, or a type of single-organ vasculitis limited to the skin. Careful evaluation is necessary to distinguish these possibilities, differentiate skin-limited from systemic disease, and identify important underlying conditions, if present. Appropriate management depends on disease type and severity. In the case of cutaneous small vessel vasculitis (CSVV), treatment is primarily based on case reports and expert opinion, using a range of immunomodulatory or immunosuppressive therapies. This manuscript presents a systematic and stepwise approach to the evaluation of patients presenting with cutaneous vasculitis, as well as the management of those diagnosed with CSVV, using best available evidence. Studies relevant to the classification, evaluation, and management of skin vasculitis are ongoing.
Literature
1.
go back to reference Sunderkötter CH, Zelger B, Chen KR, et al. Nomenclature of cutaneous vasculitis: dermatologic addendum to the 2012 revised international chapel hill consensus conference nomenclature of vasculitides. Arthritis Rheumatol. 2018;70:171–84.CrossRef Sunderkötter CH, Zelger B, Chen KR, et al. Nomenclature of cutaneous vasculitis: dermatologic addendum to the 2012 revised international chapel hill consensus conference nomenclature of vasculitides. Arthritis Rheumatol. 2018;70:171–84.CrossRef
2.
go back to reference Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill consensus conference nomenclature of vasculitides. Arthritis Rheum. 2013;65:1–11.CrossRef Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill consensus conference nomenclature of vasculitides. Arthritis Rheum. 2013;65:1–11.CrossRef
3.
go back to reference Goeser MR, Laniosz V, Wetter DA. A practical approach to the diagnosis, evaluation, and management of cutaneous small-vessel vasculitis. Am J Clin Dermatol. 2014;15(4):299–306.CrossRef Goeser MR, Laniosz V, Wetter DA. A practical approach to the diagnosis, evaluation, and management of cutaneous small-vessel vasculitis. Am J Clin Dermatol. 2014;15(4):299–306.CrossRef
4.
go back to reference Robson JC, Grayson PC, Ponte C, Suppiah R, Craven A, Judge A, et al., DCVAS Study Group. 2022 American College of Rheumatology/European Alliance of Associations for rheumatology classification criteria for granulomatosis with polyangiitis. Arthritis Rheumatol. 2022;74(3):393–9. Robson JC, Grayson PC, Ponte C, Suppiah R, Craven A, Judge A, et al., DCVAS Study Group. 2022 American College of Rheumatology/European Alliance of Associations for rheumatology classification criteria for granulomatosis with polyangiitis. Arthritis Rheumatol. 2022;74(3):393–9.
5.
go back to reference Xu LY, Esparza EM, Anadkat MJ, et al. Cutaneous manifestations of vasculitis. Semin Arthritis Rheum. 2009;38(5):348–60.CrossRef Xu LY, Esparza EM, Anadkat MJ, et al. Cutaneous manifestations of vasculitis. Semin Arthritis Rheum. 2009;38(5):348–60.CrossRef
6.
go back to reference Micheletti RG, Chiesa Fuxench Z, Craven A, et al. Cutaneous manifestations of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheumatol. 2020;72:1741–7.CrossRef Micheletti RG, Chiesa Fuxench Z, Craven A, et al. Cutaneous manifestations of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheumatol. 2020;72:1741–7.CrossRef
7.
go back to reference Mann S, Hussain A, Dua A, et al. Quality-of-life impact of cutaneous vasculitis: findings from the VascSkin study and vasculitis patient-powered research network [abstract]. In: 20th international vasculitis and ANCA workshop; Dublin; 2022. Mann S, Hussain A, Dua A, et al. Quality-of-life impact of cutaneous vasculitis: findings from the VascSkin study and vasculitis patient-powered research network [abstract]. In: 20th international vasculitis and ANCA workshop; Dublin; 2022.
8.
go back to reference Carlson JA. The histological assessment of cutaneous vasculitis. Histopathology. 2010;56(1):3.CrossRef Carlson JA. The histological assessment of cutaneous vasculitis. Histopathology. 2010;56(1):3.CrossRef
9.
go back to reference Minz RW, Chhabra S, Singh S, et al. Direct immunofluorescence of skin biopsy: perspective of an immunopathologist. Indian J Dermatol Venereol Leprol. 2010;76:150.CrossRef Minz RW, Chhabra S, Singh S, et al. Direct immunofluorescence of skin biopsy: perspective of an immunopathologist. Indian J Dermatol Venereol Leprol. 2010;76:150.CrossRef
10.
go back to reference Linskey KR, Kroshinsky D, Mihm MC Jr, Hoang MP. Immunoglobulin A-associated small-vessel vasculitis: a 10-year experience at the Massachusetts General Hospital. J Am Acad Dermatol. 2012;66:813–22.CrossRef Linskey KR, Kroshinsky D, Mihm MC Jr, Hoang MP. Immunoglobulin A-associated small-vessel vasculitis: a 10-year experience at the Massachusetts General Hospital. J Am Acad Dermatol. 2012;66:813–22.CrossRef
11.
go back to reference Micheletti RG, Werth VP. Small vessel vasculitis of the skin. Rheum Dis Clin N Am. 2015;41(1):21–32 (vii). Micheletti RG, Werth VP. Small vessel vasculitis of the skin. Rheum Dis Clin N Am. 2015;41(1):21–32 (vii).
12.
go back to reference Micheletti RG. Cutaneous vasculitis in rheumatologic disease: current concepts of skin and systemic manifestations. Clin Dermatol. 2018;36(4):561–6. Micheletti RG. Cutaneous vasculitis in rheumatologic disease: current concepts of skin and systemic manifestations. Clin Dermatol. 2018;36(4):561–6.
13.
go back to reference Loricera J, Calvo-Rio V, Ortiz-Sanjuan F, et al. The spectrum of paraneoplastic cutaneous vasculitis in a defined population: incidence and clinical features. Medicine (Baltimore). 2013;92(6):331–43.CrossRef Loricera J, Calvo-Rio V, Ortiz-Sanjuan F, et al. The spectrum of paraneoplastic cutaneous vasculitis in a defined population: incidence and clinical features. Medicine (Baltimore). 2013;92(6):331–43.CrossRef
14.
go back to reference Loricera J, Blanco R, Ortiz-Sanjuan F, et al. Single-organ cutaneous small-vessel vasculitis according to the 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides: a study of 60 patients from a series of 766 cutaneous vasculitis case. Rheumatology (Oxford). 2015;54(1):77–82.CrossRef Loricera J, Blanco R, Ortiz-Sanjuan F, et al. Single-organ cutaneous small-vessel vasculitis according to the 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides: a study of 60 patients from a series of 766 cutaneous vasculitis case. Rheumatology (Oxford). 2015;54(1):77–82.CrossRef
15.
go back to reference Martinez-Taboada VM, Blanco R, Garcia-Fuentes M. Rodriguez-Valverde V. Clinical features and outcome of 95 patients with hypersensitivity vasculitis. Am J Med. 1997;102:186–91. Martinez-Taboada VM, Blanco R, Garcia-Fuentes M. Rodriguez-Valverde V. Clinical features and outcome of 95 patients with hypersensitivity vasculitis. Am J Med. 1997;102:186–91.
16.
go back to reference Carlson JA, Chen KR. Cutaneous vasculitis update: small vessel neutrophilic vasculitis syndromes. Am J Dermatopathol. 2006;28:486–506.CrossRef Carlson JA, Chen KR. Cutaneous vasculitis update: small vessel neutrophilic vasculitis syndromes. Am J Dermatopathol. 2006;28:486–506.CrossRef
17.
go back to reference Sais G, Vidaller A, Jucgla A, et al. Prognostic factors in leukocytoclastic vasculitis: a clinicopathologic study of 160 patients. Arch Dermatol. 1998;134:309–15.CrossRef Sais G, Vidaller A, Jucgla A, et al. Prognostic factors in leukocytoclastic vasculitis: a clinicopathologic study of 160 patients. Arch Dermatol. 1998;134:309–15.CrossRef
18.
go back to reference Walls AC, Din RS, Okhovat JP, et al. Retrospective analysis of symptomatology, comorbidities and diagnostic evaluation of adults presenting with initial episode of leukocytoclastic vasculitis [abstract]. Medical Dermatology Society Annual Meeting; Washington, DC; 2016. Walls AC, Din RS, Okhovat JP, et al. Retrospective analysis of symptomatology, comorbidities and diagnostic evaluation of adults presenting with initial episode of leukocytoclastic vasculitis [abstract]. Medical Dermatology Society Annual Meeting; Washington, DC; 2016.
19.
go back to reference Walls AC, Din RS, Okhovat JP, Chansky PB, Micheletti RG, Mostaghimi A. Low utility of radiologic imaging in evaluating cutaneous small-vessel vasculitis: a multi-institutional retrospective study. J Am Acad Dermatol. 2021;84(4):1197–9.CrossRef Walls AC, Din RS, Okhovat JP, Chansky PB, Micheletti RG, Mostaghimi A. Low utility of radiologic imaging in evaluating cutaneous small-vessel vasculitis: a multi-institutional retrospective study. J Am Acad Dermatol. 2021;84(4):1197–9.CrossRef
20.
go back to reference Gonzalez-Gay MA, Garcia-Porrua C, Salvarani C, Lo Scocco G, Pujol RM. Cutaneous vasculitis: a diagnostic approach. Clin Exp Rheumatol. 2003;21(6 Suppl 32):S85–8. Gonzalez-Gay MA, Garcia-Porrua C, Salvarani C, Lo Scocco G, Pujol RM. Cutaneous vasculitis: a diagnostic approach. Clin Exp Rheumatol. 2003;21(6 Suppl 32):S85–8.
21.
go back to reference Russell JP, Gibson LE. Primary cutaneous small vessel vasculitis: approach to diagnosis and treatment. Int J Dermatol. 2006;45(1):3–13.CrossRef Russell JP, Gibson LE. Primary cutaneous small vessel vasculitis: approach to diagnosis and treatment. Int J Dermatol. 2006;45(1):3–13.CrossRef
22.
go back to reference Micheletti RG, Pagnoux C. Management of cutaneous vasculitis. Presse Med. 2020;49(3): 104033.CrossRef Micheletti RG, Pagnoux C. Management of cutaneous vasculitis. Presse Med. 2020;49(3): 104033.CrossRef
23.
go back to reference Callen JP. Colchicine is effective in controlling chronic cutaneous leukocytoclastic vasculitis. J Am Acad Dermatol. 1985;13(2 Pt 1):193–200.CrossRef Callen JP. Colchicine is effective in controlling chronic cutaneous leukocytoclastic vasculitis. J Am Acad Dermatol. 1985;13(2 Pt 1):193–200.CrossRef
24.
go back to reference Sais G, Vidaller A, Jucgla A, Gallardo F, Peyri J. Colchicine in the treatment of cutaneous leukocytoclastic vasculitis. Results of a prospective, randomized controlled trial. Arch Dermatol 1995;131(12):1399–402. Sais G, Vidaller A, Jucgla A, Gallardo F, Peyri J. Colchicine in the treatment of cutaneous leukocytoclastic vasculitis. Results of a prospective, randomized controlled trial. Arch Dermatol 1995;131(12):1399–402.
25.
go back to reference Fredenberg MF, Malkinson FD. Sulfone therapy in the treatment of leukocytoclastic vasculitis. Report of three cases. J Am Acad Dermatol. 1987;16(4):772–8. Fredenberg MF, Malkinson FD. Sulfone therapy in the treatment of leukocytoclastic vasculitis. Report of three cases. J Am Acad Dermatol. 1987;16(4):772–8.
26.
go back to reference Callen JP, Spencer LV, Burruss JB, Holtman J. Azathioprine. An effective, corticosteroid-sparing therapy for patients with recalcitrant cutaneous lupus erythematosus or with recalcitrant cutaneous leukocytoclastic vasculitis. Arch Dermatol. 1991;127(4):515–22. Callen JP, Spencer LV, Burruss JB, Holtman J. Azathioprine. An effective, corticosteroid-sparing therapy for patients with recalcitrant cutaneous lupus erythematosus or with recalcitrant cutaneous leukocytoclastic vasculitis. Arch Dermatol. 1991;127(4):515–22.
27.
go back to reference Tamura RN, Krischer JP, Pagnoux C, Micheletti R, et al. A small n sequential multiple assignment randomized trial design for use in rare disease research. Contemp Clin Trials. 2016;46:48–51.CrossRef Tamura RN, Krischer JP, Pagnoux C, Micheletti R, et al. A small n sequential multiple assignment randomized trial design for use in rare disease research. Contemp Clin Trials. 2016;46:48–51.CrossRef
28.
go back to reference Haeberle MT, Adams WB, Callen JP. Treatment of severe cutaneous small-vessel vasculitis with mycophenolate mofetil. Arch Dermatol. 2012;148(8):887–8.CrossRef Haeberle MT, Adams WB, Callen JP. Treatment of severe cutaneous small-vessel vasculitis with mycophenolate mofetil. Arch Dermatol. 2012;148(8):887–8.CrossRef
29.
go back to reference Lopez LR, Davis KC, Kohler PF, Schocket AL. The hypocomplementemic urticarial-vasculitis syndrome: therapeutic response to hydroxychloroquine. J Allergy Clin Immunol. 1984;73:600–3.CrossRef Lopez LR, Davis KC, Kohler PF, Schocket AL. The hypocomplementemic urticarial-vasculitis syndrome: therapeutic response to hydroxychloroquine. J Allergy Clin Immunol. 1984;73:600–3.CrossRef
30.
go back to reference Nurnberg W, Grabbe J, Czametzki BM. Synergistic effects of pentoxifylline and dapsone in leucocytoclastic vasculitis. Lancet. 1994;343(8895):491.CrossRef Nurnberg W, Grabbe J, Czametzki BM. Synergistic effects of pentoxifylline and dapsone in leucocytoclastic vasculitis. Lancet. 1994;343(8895):491.CrossRef
31.
go back to reference Chung L, Funke AA, Chakravarty EF, et al. Successful use of rituximab for cutaneous vasculitis. Arch Dermatol. 2006;142(11):1407–10.CrossRef Chung L, Funke AA, Chakravarty EF, et al. Successful use of rituximab for cutaneous vasculitis. Arch Dermatol. 2006;142(11):1407–10.CrossRef
32.
go back to reference Mang R, Ruzicka T, Stege H. Therapy for severe necrotizing vasculitis with infliximab. J Am Acad Dermatol. 2004;51(2):321–2.CrossRef Mang R, Ruzicka T, Stege H. Therapy for severe necrotizing vasculitis with infliximab. J Am Acad Dermatol. 2004;51(2):321–2.CrossRef
33.
go back to reference Ong CS, Benson EM. Successful treatment of chronic leucocytoclastic vasculitis and persistent ulceration with intravenous immunoglobulin. Br J Dermatol. 2000;143(2):447.CrossRef Ong CS, Benson EM. Successful treatment of chronic leucocytoclastic vasculitis and persistent ulceration with intravenous immunoglobulin. Br J Dermatol. 2000;143(2):447.CrossRef
34.
go back to reference Tosca A, Ioannidou DJ, Katsantonis JC, Kyriakis KP. Cyclosporin A in the treatment of cutaneous vasculitis. Clinical and cellular effects. J Eur Acad Dermatol Venereol. 1996;6:135–41. Tosca A, Ioannidou DJ, Katsantonis JC, Kyriakis KP. Cyclosporin A in the treatment of cutaneous vasculitis. Clinical and cellular effects. J Eur Acad Dermatol Venereol. 1996;6:135–41.
35.
go back to reference Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: a comprehensive review: a review of glucocorticoid pharmacology and bone health. J Am Acad Dermatol. 2017;76(1):1–9.CrossRef Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: a comprehensive review: a review of glucocorticoid pharmacology and bone health. J Am Acad Dermatol. 2017;76(1):1–9.CrossRef
36.
go back to reference Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: a comprehensive review: gastrointestinal and endocrinologic side effects. J Am Acad Dermatol. 2017;76(1):11–6.CrossRef Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: a comprehensive review: gastrointestinal and endocrinologic side effects. J Am Acad Dermatol. 2017;76(1):11–6.CrossRef
37.
go back to reference Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: a comprehensive review: infectious complications and vaccination recommendations. J Am Acad Dermatol. 2017;76(2):191–8.CrossRef Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: a comprehensive review: infectious complications and vaccination recommendations. J Am Acad Dermatol. 2017;76(2):191–8.CrossRef
38.
go back to reference Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: a comprehensive review: ocular, cardiovascular, muscular, and psychiatric side effects and issues unique to pediatric patients. J Am Acad Dermatol. 2017;76(2):201–7.CrossRef Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: a comprehensive review: ocular, cardiovascular, muscular, and psychiatric side effects and issues unique to pediatric patients. J Am Acad Dermatol. 2017;76(2):201–7.CrossRef
Metadata
Title
Cutaneous Small Vessel Vasculitis: A Practical Guide to Diagnosis and Management
Author
Robert G. Micheletti
Publication date
29-10-2022
Publisher
Springer International Publishing
Published in
American Journal of Clinical Dermatology / Issue 1/2023
Print ISSN: 1175-0561
Electronic ISSN: 1179-1888
DOI
https://doi.org/10.1007/s40257-022-00736-6

Other articles of this Issue 1/2023

American Journal of Clinical Dermatology 1/2023 Go to the issue

Acknowledgement to Referees

Acknowledgment to Referees