Plant-Based Diet Appeared To Help Patient With Livedoid Vasculopathy

A 63-year-old woman's long-standing lower leg ulcerations from livedoid vasculopathy went into remission after she adopted a whole-foods, plant-based diet, according to a case report from New Zealand.

The authors note that whenever the patient has deviated from this diet over the past three to four years, her symptoms start to return, yet renewed adherence to the diet has always brought symptom relief.

The diet allows all vegetables, fruits, legumes, grains, herbs and spices, though high-fat plant foods, such as avocado and coconut, are limited. Meat, dairy, eggs, fried foods, heavily processed foods and all refined oils are excluded by the diet.

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Lead author Morgen Smith of the Plant Based New Zealand Health Trust in Gisborne told Reuters Health by email that the diet in question is described in the book "Prevent and Reverse heart disease," by Dr. Caldwell B. Esselstyn Jr.

"Unfortunately," she added, "the term 'plant-based' has become more popular and has been appropriated to mean all sorts of things, which is why we continue to define the diet in our research."

Livedoid vasculopathy (LV) is a rare condition of unknown cause that affects about one person in 100,000. The mean age of onset is 32, and the condition is three times as likely to affect women as men.

LV presents with highly painful ulcers, usually 4 to 6 mm in size, caused by thrombotic occlusion of cutaneous capillaries of the legs. These ulcers are followed by white, painless scars.

The patient experienced an onset of symptoms in 2005. She had sporadically itching red blotches on her lower legs and feet, and in 2006 she began taking prescription ibuprofen daily and codeine occasionally.

The diagnosis at that time was nonspecific capillaritis. The patient wore compression stockings to help reduce ulcer formation and swelling.

Every few weeks or months starting in 2008, the blotches formed into painful oozing ulcers from 1 to 10 mm in size.

Findings of a punch biopsy in 2013 were consistent with a vascular occlusive disorder, specifically LV.

In 2016, the patient, then age 63, presented with a 1 by 2 cm ulcer on her left lower leg. Antibiotics were prescribed, as these had helped previously.

The patient was normotensive and had a BMI of 28.5. Blood tests were unremarkable. The patient expressed a desire to "try anything," at which point she was advised to read Dr. Esselstyn's book.

She did, and a month later, she returned and stated that her lesions had begun healing and that her symptoms were less bothersome than they had been in years.

By March 2017, the patient felt that she was symptom-free and stopped wearing compression stockings.

Since that time, the patient reportedly has been symptom-free, except after periods (such as Christmas 2019) when she consumed foods such as fatty meats, cheese and oil.

The authors propose three explanations for the patient's remission. First, some foods, such as high-fat meals, can inhibit the ability of endothelial cells to produce nitric oxide, which has both anticoagulant and anti-inflammatory effects.

Second, saturated fats from animal products can increase gastrointestinal permeability, allowing incompletely digested foreign proteins to enter the bloodstream, possibly triggering the formation of antibodies.

Third, bacterial endotoxins originating from animal foods can cause acute inflammation, an effect not seen with the consumption of fruits and vegetables.

A 2018 systematic review showed that anticoagulants generally are more effective than anti-inflammatory medications in treating LV. Dr. Afsaneh Alavi of the Mayo Clinic, in Rochester, Minnesota, who co-authored that review, said that overall LV presents in a young patient population, so it's likely that these patients had other issues besides vessel-wall problems.

She also pointed out that in a German study from 2019, most patients had high BMI and high blood pressure and showed increased blood levels of homocysteine.

Dr. Alavi, who was not involved with the New Zealand report, said she's not surprised that a better diet might help treat LV, perhaps by multiple mechanisms including altering the patient's microbiome. But she was surprised that it might have brought about remission. She called using diet to treat LV is an "interesting concept."

The authors declared no specific funding for this case report. Smith and another co-author offer free plant-based diet resources online.

—Scott Baltic

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