Dear Editor,
It was indeed a pleasure to read a case report on use of Hyperbaric oxygen therapy (HBO2T) for livedoid vasculopathy published in MJAFI 2012; 68:389-391. It is high time we recognise the use of HBO2T in such disorders where the patho-physiology of the disease has a definite element of hypoxia to the tissue, which in this disease is due to intra-luminal coagulation. In such disorders only medications are not able to halt/reverse the progression of the disease, provide relief to patients and decrease the morbidity or mortality. I would like to complement the author for recognising the potential of HBO2T for such not so well recognised indication and relieving the suffering of the patients. However, I would like to ask for certain clarification as far as the use of HBO2T for such disorders is concerned.
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(i)
Is it not mandatory to check the partial pressure of oxygen (PO2) of the area in the immediate vicinity of the ulcer by using transcutaneous oxygen measurements or certain other indirect methods before starting the therapy to be sure that there is going to be definite benefit of the HBO2T.
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(ii)
The average duration of relief in pain in the series conducted by Juan et al was 4.9 HBO sessions whereas in this particular study the same was achieved at the end of 18 sessions for 1st patient and 17 sessions for the 2nd patient. Was it because of the severity of disease in these patients, the technique of giving HBO2T or due to certain other reasons.
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(iii)
It is not clear whether the other medications were also stopped or only analgesics were stopped following improvement. Also certain studies have noted that hyperhomocysteinemia can be another cause of hypercoagulability in this disease and combination of folic acid, vitamin B-12, and vitamin B-6 (cofactors of homocysteine metabolism) are an effective treatment for hyperhomocysteinemia, hypercoagulability, and livedoid vasculopathy. Were they also used in these patients.1
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(iv)
Last but not the least, how does one decides the end point of the therapy or when to stop. Is it symptomatic relief, complete healing of ulcers, no improvement despite therapy or any other criteria.
In the end I would like to complement the editor for selecting such interesting case report related to use of HBO2T. It will definitely give a wide publicity for use of HBO2T in such intractable disorders among all doctors and specially those serving in armed forces.
Reference
- 1.Meiss F., Marsch W.C., Fischer M. Livedoid vasculopathy. The role of hyperhomocysteinemia and its simple therapeutic consequences. Eur J Dermatol. Mar–Apr 2006;16(2):159–162. [PubMed] [Google Scholar]