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For further information, see CMDT Part 22-29: Livedo Reticularis & Livedo Racemosa

KEY FEATURES

Livedo reticularis

  • Idiopathic livedo reticularis is a benign condition that primarily affects the extremities

  • Usually asymptomatic (apart from cosmetic concerns)

  • Produces a mottled, purplish discoloration of the skin in a "fishnet” pattern with reticulated cyanotic areas surrounding paler central cores

  • Consider an underlying disease when

    • Systemic symptoms are present

    • Cutaneous ulcerations develop

Livedo racemose

  • Also known as secondary livedo reticularis

  • Occurs with diseases that cause vascular obstruction or inflammation

CLINICAL FINDINGS

Livedo reticularis

  • Spasm or obstruction of perpendicular arterioles combined with pooling of blood in surrounding venous plexuses

  • Worsens with cold exposure

  • Improves with warming

  • Consider an underlying disease when

    • Systemic symptoms are present

    • Cutaneous ulcerations develop

Livedo racemosa

  • Resembles idiopathic livedo reticularis

  • Has a wider skin distribution (often found on trunk and buttocks as well as extremities)

  • Lesions are more irregular, broken, and circular

  • Presenting manifestation of 25% of patients with antiphospholipid antibody syndrome

  • Strongly associated with the subgroup that has arterial thromboses, including those with antiphospholipid antibody–positive Sneddon syndrome (livedo reticularis and cerebrovascular events)

  • Other underlying causes include

    • Vasculitides (particularly polyarteritis nodosa)

    • Cholesterol emboli syndrome

    • Thrombocythemia

    • Cryoglobulinemia

    • Cold agglutinin disease

    • Primary hyperoxaluria (due to vascular deposits of calcium oxalate)

    • Disseminated intravascular coagulation

DIAGNOSIS

  • Clinical

  • Livedo reticularis must be distinguished from erythema ab igne, a benign cutaneous disorder caused by exposure to an infrared heat source (eg, heating pad, laptop computer)

TREATMENT

  • Protection from exposure to cold

  • Vasodilators seldom indicated

  • If ulcerations or gangrene, exclude an underlying systemic disease

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