- 1 What is livedo reticularis?
- 2 What are the causes of livedo reticularis?
- 3 What are the signs and symptoms of livedo reticularis?
- 4 What are the risk factors of livedo reticularis?
- 5 How is livedo reticularis diagnosed?
- 6 How is livedo reticularis treated?
- 7 What is idiopathic livedo reticularis?
What is livedo reticularis?
Livedo reticularis is the appearance of a mottled discolouration of the skin. This discolouration has a net like or lace like pattern. It has a cyanotic or bluish discoloration which surrounds a central, pale area.
There are different types of livedo reticularis. They are:
This term refers to livedo reticularis seen in infants and young children. It is a physiological and temporary response seen against cold. However, there has been some rare cases, where this livedo reticularis has persisted and such cases were usually caused by an underlying congenital disorder.
Physiological livedo reticularis
As the name suggests, this is the physiological response of livedo reticularis in response to cold exposure.
Primary livedo reticularis or idiopathic livedo reticularis
This refers to a benign form of livedo reticularis where the underlying cause is not known.
Secondary livedo reticularis
This refers to a persistent form of livedo reticularis which occurs secondary to an underlying medical condition.
Livedo racemose refers to persistent livedo reticularis which has a generalized involvement of the body.
What are the causes of livedo reticularis?
Livedo reticularis occurs due to a disturbance in the blood flow to the skin thus leading to a reduction in the oxygen supplied to the skin. This reduction in blood flow to the skin can be due to a number of factors. So when the blood supply is reduced, this leads to accumulation of blood within the veins. Venous blood is usually the bad blood meaning deoxygenated blood carrying all the waste products. When this blood accumulates within the skin, it gives a bluish or a purplish discoloration.
As mentioned earlier, livedo reticularis can be caused by a number of causes. Out of the many causes, one major cause of livedo reticularis is the exposure to cold weather. When a patient is exposed cold weather, the arterioles located within the skin, undergo spasms thus reducing the blood flow to the exposed areas. In cases of physiological livedo reticularis, this pattern will soon disappear once that affected area is warmed or the cold environment is removed.
Other causes of livedo reticularis includes:
- Obstruction to the blood flow to the skin. For instance, if there is a blood clot in one of the blood vessels that supply blood to the skin.
- Sluggish blood flow to that area as seen in hyper viscous conditions. This also reduces the blood flow to that particular area.
- In conditions that cause problems with the vessel wall such as in conditions where there is vessel wall inflammation.
Some of the conditions where this livedo reticularis pattern can be appreciated are:
- Systemic lupus erythematosus
- Rheumatoid arthritis
- Antiphospholipid syndrome
- Polyarteritis nodosa
- Cholesterol emboli syndrome
What are the signs and symptoms of livedo reticularis?
Livedo reticularis may show the following characteristic signs and symptoms:
- A net or mesh or lace like pattern on the skin with a purplish or a reddish blue discoloration.
- This pattern can be transient, lasting only for a short period of time and disappear on its own without any treatment or it can be persistent
- This appearance is frequently seen on the legs but can occur in other areas of the body as well such as the hands, back and the chest.
- The mesh or the lace like pattern may or may not improve with warming of the area.
- Exposure to cold environments may also give rise to other symptoms such as a tingling sensation of the skin or numbness of the affected area.
What are the risk factors of livedo reticularis?
- Exposure to cold weather
- The presence of an autoimmune conditions
Certain auto immune conditions which are associated with livedo reticularis and one of the most commonly associated conditions are systemic lupus erythematosus (SLE). Other autoimmune condition that can be associated with this condition are dermatomyositis, scleroderma, rheumatic fever and rheumatoid arthritis.
- Raynaud’s phenomenon
Reynaud’s phenomenon of the small arteries, especially the end arteries go into spasm when exposed to cold weather and this may predispose livedo reticularis.
- Inter current infections or history of infections
Infections such as syphilis, Parvovirus, pneumococcal sepsis, mycoplasma, Hepatitis C, Tuberculosis (TB), and meningococcemia are all associated with livedo reticularis.
- Certain medications
Drugs like Amantadine, norepinephrine, quinine, minocycline and interferon are some of the most commonly reported drugs that have induced livedo reticularis in patients.
- History of vascular studies
Vascular studies such as arteriography or catheterization. These procedures have a complication known as cholesterol emboli syndrome and may lead to livedo reticularis.
How is livedo reticularis diagnosed?
Livedo reticularis is clinical sign or in another words, it is a physical finding. It is not a disease to be diagnosed.
Livedo reticularis is often diagnosed clinical. The clinical features alone are usually sufficient to make a diagnosis of livedo reticularis. However, if there is any doubt about the diagnosis, then a skin biopsy from the area that was affected can be done to confirm the diagnosis of livedo reticularis.
It is always best to take at least 2 samples of the skin biopsy from the area with the reddish blue and white areas of the livedo reticularis pattern. Serial sections should be asked to perform out of these samples. The reason why at least 2 samples need to be taken is that even with a large skin biopsy taken from the centre of the livedo reticularis pattern may show that it is normal. Therefore take at least two samples during the skin biopsy to improve the chances of accurate diagnosis. During the skin biopsy procedure, a large punch or a wedge of the skin is taken because our aim is to take samples containing the medium sized blood vessels which are located in the deep reticular dermis and subcutaneous fat. Due to this reason, a large punch or wedge should be taken during the skin biopsy procedure to increase the chance of accurate diagnosis.
Further investigations can be done once the condition of livedo reticularis has been diagnosed and the underlying cause needs to be found. The investigations that need to be ordered are based upon the history and examination of each patient. There is no point in doing an extensive screening. If the livedo reticularis is not brought about by the exposure to cold weather, then your doctor may order lupus anticoagulant panel.
What questions will your health care provider ask you regarding this condition?
Your health care provider will ask you questions in order to get a clue about the underlying cause of the condition you have got which will help in the future investigations and management. He or she may ask you the following questions from you.
- Where is the discoloration?
- How long has this discoloration been persisting? As mentioned before, livedo reticularis Is usually transient where it goes away on its own. However, there are some variants of livedo reticularis which persists for long periods of time.
- Have you noticed any alleviating or exacerbating factors of this discoloration? The commonest exacerbating factor of livedo reticularis is exposure to cold. Usually physiological Livedo reticularis is brought on about by cold temperatures. However, primary or idiopathic livedo reticularis may not be sensitive to a change in temperature. Another type of livedo reticularis known as livedo racemose, gets accentuated with exposure to cold, yet do not disappear once the cold environment is removed or when that particular area is warmed.
Your health care provider will then go on to take a detailed medical history from you. This is important to find the underlying cause for your presentation. So take all your past medical records with you, if you have any, as this will help your health care to find the underlying cause for your condition. Some of the questions he or she may ask regarding your past medical history are:
- Do you have a history of any autoimmune diseases? Or they might ask you regarding any signs and symptoms that you may be experiencing that may suggest the presence of any autoimmune conditions. This question is asked because there are certain auto immune conditions which are associated with livedo reticularis and one of the most commonly associated conditions are systemic lupus erythematosus (SLE). Other autoimmune conditions that can be associated with this condition are dermatomyositis, scleroderma, rheumatic fever and rheumatoid arthritis.
- Have you been diagnosed with a condition known as Raynaud’s phenomenon? If not, do you experience bluish discoloration of the finger tips when exposed to cold weather? This question is asked because in Reynaud’s phenomenon of the small arteries, especially the end arteries go into spasm when exposed to cold weather and this may predispose livedo reticularis.
- Do you have a history of chronic renal disease?
- DO you have any hypercoagulable states that may predispose you to livedo reticularis? Do you have a family history or a personal history of any thromboembolic disease or an early stroke? History of a malignancy also puts you into a hypercoagulable state and therefore predispose to livedo reticularis.
- Do you have a recent history of any infection? Infections such as syphilis, Parvovirus, pneumococcal sepsis, mycoplasma, Hepatitis C, Tuberculosis (TB), and meningococcemia are all associated with livedo reticularis.
- What medications do you currently take? This question is frequently asked because there are some drugs that may induce livedo reticularis. Drugs like Amantadine, norepinephrine, quinine, minocycline and interferon are some of the most commonly reported drugs that have induced livedo reticularis in patients.
- Have you undergone any vascular studies such as arteriography or catheterization. These procedures have a complication known as cholesterol emboli syndrome and may lead to livedo reticularis.
How is livedo reticularis treated?
There is no specific treatment as such available for livedo reticularis. However, as you know that one common cause of the appearance of this livedo reticularis pattern on the skin is due to exposure to the cold, it is important that you avoid exposure to cold as a part of your management.
Most cases of livedo reticularis, spontaneously recover on its own without the need for any treatment. Warming the affected areas have also shown to be useful in the reversal of the discoloration on the skin.
The next most important step in the management of livedo reticularis is to treat the underlying cause if it is known.
What is idiopathic livedo reticularis?
Idiopathic livedo reticularis is also known as primary livedo reticularis and this refers to the presence of a mesh like purplish skin pattern where the underlying cause is not known. If the livedo reticularis is secondary to another disease, then it is referred to as secondary livedo reticularis.
Idiopathic livedo reticularis is common and there mesh like pattern of the skin is frequently seen in the lower legs. This is a result of the dilated medium sized blood vessels which are found just beneath the skin. Although, the mesh like pattern is frequently seen in the lower legs, it can also be found over the arms, chest and the back. The bluish discoloration is due to the impaired blood flow to that particular area. Idiopathic livedo reticularis is a benign condition and usually tends to get worse with exposure to cold weather.
In terms of prognosis, idiopathic or primary livedo reticularis has an excellent prognosis and often do not need treatment. In fact, there is not particular treatment available for the condition. It usually tends to go away on its own.
Who is at risk of developing idiopathic livedo reticularis?
In terms of sex, females have a higher chance of developing idiopathic livedo reticularis and out of all the females; the young to middle aged females have the highest chance of developing this condition.
The main risk factor of idiopathic livedo reticularis is the cold weather especially during the winter season.
It is important that you understand that just because you have the above mentioned risk factors does not mean that you will definitely develop the disease. It simply means that you have a higher chance to develop the condition compared to the others without any risk factors. It is also possible to have all the risk factors and yet not develop the condition. On the other hand, the absence of these risk factors does not mean that you will never get this condition. Yet, there is nothing to worry about if you do not have any of the risk factors.
What are the signs and symptoms of primary or idiopathic livedo reticularis?
The signs and symptoms of idiopathic livedo reticularis include:
- The appearance of a reddish blue or a purplish mesh like pattern over the skin.
- The affected area may be associated with loss of sensation and sometimes ulceration of the skin especially when the skin is exposed to cold weather such as during the winter season.
- The involved area of the skin may not recover once the cold environment is removed or when that particular area is warmed.
Can you prevent idiopathic or primary livedo reticularis?
The underlying cause of idiopathic or primary livedo reticularis is not known therefore this condition cannot be prevented.