Livedo Reticularis

Medically reviewed by The Dermatologists and written by Dr. Aayushi Shah

Common 

  • Lace-like bluish discoloration of skin
  • May be mild or severe
  • May or may not be associated with systemic conditions
  • Only severe cases require investigation and treatment
  • Cold avoidance and rewarming are key

Livedo Reticularis is a mottled blue discoloration of the skin, which is seen in a characteristic networked pattern. This is usually triggered by a cold environment and becomes more prominent at that time.

 

Meaning of the name

The term livedo describes a violet skin discolouration caused by an abnormality in the local blood circulation. The word reticularis suggests that it has a net-like or lace-like appearance on the skin.

Causes

Livedo reticularis occurs due to low blood flow within the skin. This leads to collection of deoxygenated blood in the venules, and slowing of flow, which lends to the bluish and lacy appearance, which is due to deoxygenated blood being collected in the dermal venules. The skin shows areas of blanching (pallor). There may be an accompanying inflammation in the blood vessel walls.
Some of the systemic conditions which lead to livedo reticularis are: obstruction of blood vessels (thrombosis), autoimmune conditions, drugs, infections, malignancies vasculopathy. Livedo reticularis has been associated with Covid-19.

Types and variants

  • Livedo reticularis: Most cases of livedo which show a lacy appearance (network-like) are described using this name.
  • Livedo racemosa: This is used to describe cases of livedo which show a branching pattern of bluish discoloration of the skin. Livedo racemose can also be generalised and persistent. It is often due to an underlying systemic condition. Livedo racemose is known to be associated with antiphospholipid antibody (APLA) syndrome.
  • Physiological livedo reticularis (cutis marmorata): This is a phenomenon where there is a transient bluish mottling of the skin, often occurring on exposure to cold. This is considered to be normal and is seen in infants, and rarely in adults as well. It changes back to normal during warm weather.
  • Congenital livedo reticularis (cutis marmorata telengiectatica): This is a rare developmental defect, present since birth. It is seen as a bluish purple vascular network, often involving one of the limbs. It may or may not be associated with anomalies in other organs. The reticular appearance remains persistent all the time, becomes more prominent in cold weather, and may resolve by itself within the first two years of life.
  • Acquired idiopathic livedo reticularis: This is a condition predominantly seen in women. It is not usually associated with any underlying cause. It might range from mild to severe.

 

Signs and Symptoms

Livedo reticularis most commonly occurs on the legs, followed by the arms and trunk. The characteristic feature is a blotchy, lace-like, cyanotic pattern which may be transient or persistent. It is more pronounced in cold environments and may disappear on warming.

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Complications

  1. Ulceration – Rarely seen, but when present it suggests an underlying pathology such as vasculitis or thrombosis which needs to be diagnosed and treated.
  2. Scarring – The appearance of livedo reticularis is initially reversible if the underlying problem is treated, but if it persists chronically, telengiectasias may develop.

 

How is it diagnosed?

The diagnosis is usually clinical, based on the appearance or photographs of the same, if it is transient. Tests may be conducted to rule out underlying causes depending on the type of livedo suspected. Skin biopsies may be performed from the cyanosed and/or pale areas of the skin affected by livedo, to confirm and check for pathologies in the vessel walls. A lupus anticoagulant panel and tests for other autoimmune conditions may also be conducted.

However, skin biopsies are not always diagnostic and sometimes the results may be normal if the changes causing it are transient.

 

What can I do?

  • Avoid extreme cold environments
  • Wear warm clothing
  • If symptoms start, rewarm the area immediately
  • Seek medical help if you notice persistent symptoms
  • Seek medical help if you develop pain or ulceration.

 

Treatment

There is no specific treatment for most cases of livedo reticularis. In mild cases without other systemic symptoms, it is often left untreated. Cold avoidance is very important to avoid flare-ups. When associated with underlying conditions, those need to be treated for improvement in the symptoms of livedo. Drugs such as aspirin may be prescribed along with lifestyle modification, and smoking cessation.

 

 

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Source:
1.  Sajjan VV, Lunge S, Swamy MB, Pandit AM. Livedo reticularis: A review of the literature. Indian Dermatol Online J. 2015;6(5):315-321. doi:10.4103/2229-5178.164493

2. Griffiths C EM, Barker J, Bleiker T, Chalmers R, Creamer D. Rook’s Textbook of Dermatology. 9th Ed. Wiley Blackwell. 2016.

 

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