What You Should Know About Livedo Reticularis

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Livedo reticularis is a particular kind of skin discoloration, consisting of a reddish-purplish, web-like pattern that forms circles, typically on the legs or arms. Livedo reticularis is a common (and temporary) phenomenon in babies and in younger women who are exposed to cold temperatures, and in these cases it is completely benign. However, it can also be seen with several serious underlying medical conditions. 

If livedo reticularis occurs outside the setting of its typical, benign pattern, that may be the first clue that a complete medical evaluation is needed.

Causes

Livedo reticularis is usually divided into two categories: physiologic and pathologic.

Physiologic Livedo Reticularis

Physiologic livedo reticularis is a phenomenon seen quite commonly in people who have no underlying disease process, and is usually considered a variant of normal.

In people who experience physiologic livedo reticularis, exposure to cold causes some of the arterioles (small arteries) that supply the skin to constrict, so the blood supply to the skin is diminished. The center of the patch of skin supplied by this constricted artery becomes pale, and the blood trapped in the tiny blood vessels along the perimeter of the area supplied by this arteriole becomes purplish in color (because it is deoxygenated). The result is a circular, web-like pattern of purplish discoloration with a pale center.

Because many arterioles will become constricted in cold temperatures, livedo reticularis typically forms a large network of these circular discolorations. When the skin warms up, the constricted arterioles open up and the livedo reticularis disappears. 

Physiologic livedo reticularis is considered a normal phenomenon, most commonly seen in babies and young to middle-aged women.

Pathological Livedo Reticularis

Pathological livedo reticularis (sometimes called livedo racemosa) is also caused by a blockage of the penetrating arterioles that supply the skin tissue. But here, the blockage is caused by something other than a physiological constriction of the blood vessel, and depending on the underlying cause, the rash may be permanent and not transient. 

There are numerous medical conditions that can lead to pathological livedo reticularis, including:

Symptoms

Physiologic livedo reticularis: A distinctive skin discoloration is the only symptom. It consists of a reddish-purplish discoloration that is finely reticulated (web-like), and that forms numerous circular patterns on the skin surface.

Livedo reticularis is most common on the arms and legs. The circular formations tend to be complete, with some broken segments. The centers of these circles are typically quite pale. The discoloration is entirely “flat,” that is, there are no lumps or bumps. It is not painful. It is simply a discoloration. 

Physiologic livedo reticularis appears transiently when a person is exposed to the cold, and resolves when the skin is warmed up.

Pathological livedo reticularis: The symptoms may be identical to those seen with physiological livedo reticularis. However, when livedo reticularis is caused by a serious underlying medical problem, the pattern of discoloration is often atypical.

In pathological livedo reticularis, the color of the affected skin is often strikingly violet, and is more likely to form a highly irregular pattern of broken circles rather than complete, regular circles. The skin changes also tend to be more widespread, and in addition to the arms and legs, it is commonly seen on the trunk and buttocks, and may even become generalized . A nodule or an ulcer may be present in the center of the circular patterns, and if so, significant pain may result. The skin discoloration in pathological livedo reticularis tends to be permanent, and not merely transient—and is often not noticeably associated with cold temperatures.

Given the wide range of medical disorders that can cause pathological livedo reticularis, this phenomenon often occurs in association with any of a number of symptoms particular to the underlying cause.

Diagnosis

The diagnosis of livedo reticularis itself is usually straightforward, given the distinctive appearance of this phenomenon, and the typical circumstances in which it occurs. In the vast majority of cases, livedo reticularis is a normal phenomenon, and no additional testing is needed.

The diagnosis can become challenging if the skin discoloration, or the circumstances in which it appears, suggest a non-physiologic cause, that is, if the condition appears to be pathological. In these cases, the doctor needs to begin with a thorough medical history and physical examination, looking for clues to one of the very many medical problems that can produce this phenomenon. When such clues are found, targeted diagnostic testing should be done to look for the suspected diagnosis.

If the initial evaluation points in no particular direction, the doctor will usually begin with screening blood tests—a complete blood count and a metabolic panel. Blood tests to screen for cold agglutinins, antiphospholipids, cryoglobulins, cryofibrinogens, autoimmune disease, and coagulation disorders might also be done. CT scanning or MRI scanning also might be done if cancer is suspected. A skin biopsy can also be helpful in diagnosing the underlying cause.

Typically, if pathological livedo reticularis is present such screening tests will point in the right direction.

Treatment

Physiological livedo reticularis is a normal, transient phenomenon that has no known medical consequences. Aside from warming up the skin, no treatment is required.

Because the underlying medical problems associated with pathological livedo reticularis tend to be serious and potentially life-threatening issues, once the correct diagnosis is made treatment should be aimed at eliminating or ameliorating that underlying cause.

A Word From Verywell

Livedo reticularis is most typically a common, benign, and transient skin discoloration associated with a normal circulatory system being exposed to cold. In some cases, however, livedo reticularis is caused by a serious underlying medical problem. The pattern of the discoloration and the circumstances in which it occurs should provide the doctor with important clues as to whether livedo reticularis requires a full medical evaluation, or merely reassurance.

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Article Sources

  1. Goyal P, Daval S, Sahu P. Generalized Livedo Reticularis: A Rare Variety. Indian Ju Dermatol. 2019 Jan-Feb;645(1):59-61 doi: doi: 10.4103/ijd.IJD24618

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