FFinalistSouthampton · 2027
Dermatology
AKT · Dermatology/Reactive & systemic signslow yield

Livedo reticularis

Mottled skin from disturbed dermal blood flow

Overview

A net-like (reticulated), mottled, purplish discolouration of the skin from sluggish/obstructed dermal microcirculation. Benign physiological cutis marmorata (cold-induced, reversible) versus a pathological persistent pattern pointing to vasculopathy — the antiphospholipid syndrome being the high-yield association.

Recognise

  • A reticulated (net-like) violaceous mottling, usually on the limbs
  • Physiological (cutis marmorata): symmetrical, reversible on warming, common in infants/young women
  • Pathological (persistent, broken/irregular = livedo racemosa): does not fade on warming, points to a systemic vasculopathy

Red flags

  • Persistent/irregular livedo with ulceration, thrombosis, or systemic features → antiphospholipid syndrome, SLE, vasculitis, cholesterol embolism, or polyarteritis nodosa

Differentials & how to tell them apart

Cutis marmorata (physiological)symmetrical and reverses on warming — pathological livedo persists and is irregular
Erythema ab ignereticulated pigmentation from chronic heat exposure (laptop/heater), fixed
Vasculitis/PANwith nodules, ulcers, systemic features

Clinical image

We can't host this one — the image is DermNet's and their licence doesn't cover us republishing it. Their page for it is free to view.

Livedo reticularis — clinical imagesDermNet

Investigations

If pathological — antiphospholipid antibodies/lupus anticoagulant, ANA, vasculitis screen; consider cholesterol embolism (after vascular procedures) and PAN. Biopsy if vasculitis suspected.

Management

Reassure if physiological; investigate and treat the underlying cause if persistent

  1. 1Determine physiological vs pathological. Cold-induced symmetrical livedo that reverses on warming (cutis marmorata) → reassure.Gate: Persistent, irregular ("racemosa") livedo that does NOT fade on warming, or comes with thrombosis/ulceration, demands a systemic work-up — the high-yield link is ANTIPHOSPHOLIPID SYNDROME (also SLE, vasculitis, cholesterol emboli)
  2. 2Pathological → investigate and treat the cause (anticoagulation for APS, immunosuppression for vasculitis/SLE).
Reassurance + keep warm — physiological cutis marmorata needs nothing
Treat the underlying disease — anticoagulation for antiphospholipid syndrome; immunosuppression for vasculitis/SLE

Key points

The key discrimination is reversible-on-warming (benign) vs persistent/irregular (pathological → think antiphospholipid syndrome). Erythema ab igne is the heat-exposure mimic.

Monitor & prognosis

Underlying disease activity if pathological.

Physiological is benign; pathological follows the underlying disease.

Source: DermNet; StatPearls