Livedo reticularis (LR) is a common vascular reaction pattern characterized by a reticular (net-like) discoloration on the extremities and trunk. It is caused by decreased blood flow to the skin or impaired outflow in the dermal venous plexus and stagnation of the blood within these vessels. The darker, discolored areas represent accumulation of deoxygenated blood. Etiologic categories include vasospasm, vessel wall dysfunction (eg, vasculitis), and vascular flow compromise as in coagulopathies.
LR is exacerbated by cold temperatures. It may be physiologic (cutis marmorata), a primary disease (as in idiopathic cases), or it may be secondary to underlying disorders such as antiphospholipid antibody syndrome, vasculopathies, or autoimmune connective tissue disorders. Amantadine, quinidine, and catecholamines have also been described as triggers. Drugs used in the past to treat syphilis (bismuth and arsphenamine) also caused LR. Furthermore, infections can induce LR via the formation of cryoglobulins, cold agglutinins, septic emboli, immune vasculitis, or septic vasculitis. In adults, LR is frequently seen in patients with Raynaud phenomenon, in those with a predisposition to chilblains and acrocyanosis, and in patients with poor vascular flow (eg, peripheral vascular disease and cardiac failure).
These secondary forms may also present with livedo racemosa, where the reticular pattern is asymmetric, discontinuous, and localized. Localized forms may be associated with vasculitis. In severe cases, the extremities are cold and ulcers may form.
Sneddon syndrome is extensive diffuse LR or livedo racemosa with cerebrovascular disease (from transient ischemic attacks to frank cerebrovascular accidents), hypertension, and antiphospholipid antibodies.
ICD10CM: R23.1 – Pallor
SNOMEDCT: 238772004 – Livedo reticularis
Differential Diagnosis & Pitfalls
Erythema ab igne is a form of fixed reticulate dyspigmentation in skin with chronic repeated heat exposure.
Cutis marmorata telangiectatica congenita often only involves one extremity although it can be more generalized. It is usually present at birth and may be associated with limb asymmetry, vascular anomalies, or neurologic abnormalities.
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
Livedo reticularis is a harmless, lacy, symmetrical skin pattern of small blood vessels. It usually appears on the legs, especially when exposed to cold temperatures. It is caused by blood pooling in the veins. It can be associated with Raynaud syndrome, antiphospholipid syndrome, Sneddon syndrome, or lupus.
Who’s At Risk
Young women (aged 20 to 40) exposed to cold temperatures, smoking, and stress may develop the distinctive lacy skin pattern of livedo reticularis.
Some medications increase the risk of developing livedo reticularis.
Signs & Symptoms
Livedo reticularis is a reddish-blue symmetrical skin pattern most commonly seen on the legs. It may appear on the arms, chest, or abdomen. It gets worse when exposed to cold temperatures, and the skin feels cold to the touch.
Avoid tobacco use and wear warm clothing to protect skin from cold temperatures. If skin is cold, gradually rewarm exposed skin.
Elevating the affected leg may help impaired circulation.
When to Seek Medical Care
Check with your doctor if you develop skin ulcers or symptoms of small blood vessel inflammation, such as:
General aches and pains
Numbness or weakness
There is no general treatment for livedo reticularis, but your health care provider will want to find out if it is being caused by an underlying disease.