Causes and Pictures of Mottled Skin (Livedo Recticularis)

Livedo reticularis (LR), also known as mottled skin, is a type of skin discoloration that can occur if there is an interruption of blood flow to the skin. This is often a temporary, harmless phenomenon that is the result of exposure to cold temperatures or stress. It can also appear because of several serious underlying conditions.

Skin affected by livedo reticularis usually has reddish-purplish discoloration with web-like, mottled, or blotchy circular patterns on legs or arms. Skin appearance can differ depending on the cause, however.

Because livedo reticularis more frequently impacts babies and assigned females between the ages of 20 and 50, such skin discoloration in others—particularly without cold temperature exposure or stress—may be the first indication that a medical evaluation is needed.

This article explains the causes and symptoms of livedo reticularis, as well as how it is diagnosed and treated. It also discusses cases when you should worry about livedo reticularis and contact your healthcare provider.

What Is Mottled Skin?

Mottled skin, or livedo reticularis, appears as a lace-, net-, or web-like pattern on the skin. The pattern varies in color but is usually shades of red, purple, blue, or brown. Discoloration most often appears as blotchy skin on the legs.

Mottled skin appears where blood flow near the skin's surface has changed. This change could be due to reduced levels of oxygen in the blood beneath the skin, spasms in the blood vessels, or alterations in blood circulation.

Livedo reticularis can result from many causes such as cold exposure, as a symptom of a medical condition, or as a drug side effect. Sometimes the cause of livedo reticularis is unknown.

Terms you may hear after a livedo reticularis diagnosis may include:

• Physiologic LR (cutis marmorata): Considered a variation of normal, PLR is a temporary reaction triggered by cold weather or stress. It is commonly seen in people who have no underlying medical conditions.
• Primary LR: This benign intermittent mottled skin is unrelated to temperature and without known cause.
• Idiopathic LR: A persistent and unresolving form of LR, it is diagnosed when no other conditions are found. Rarely, ILR signals the early stage of antiphospholipid syndrome (APS) or Sneddon's syndrome.

Drug-induced LR is a condition that results as a side effect of certain medications, notably amantadine (used to treat Parkinson's disease).

Secondary LR or livedo racemosa (LRC) is a generalized and persistent form of LR associated with an underlying condition. It differs from other forms of LR by location (more widespread and found on the limbs, trunk, and buttocks), shape (irregular, broken, circular patches), and biopsy results.

Secondary LR is a classical sign of Sneddon's syndrome but is also seen in other underlying health conditions, such as diabetes, infection, or autoimmune disorders.

A Word From Verywell

Livedo reticular is a rash that appears as a result of spasms in superficial blood vessels. While some forms are innocuous, it's important to evaluate for possible underlying medical conditions that can be associated with this unique skin eruption.

— BRENDAN CAMP, MD, MEDICAL EXPERT BOARD

What Are the Causes of Livedo Reticularis?

Many different conditions and diseases can trigger an LR reaction.

Cold

When blood vessels constrict due to cold temperatures, physiologic livedo reticularis can occur. It is most commonly seen on the legs during exposure to cold temperatures. The mottling slowly resolves when the skin is warmed. Cold LR is considered a harmless condition and no treatment is required.

Septic Shock

LR skin mottling may be a sign of septic shock, a severe, life-threatening medical condition in which the immune system has an extreme response to an infection. 

Antiphospholipid Syndrome

As mentioned above, idiopathic livedo reticularis can be an early symptom of antiphospholipid syndrome (APS) in rare cases. APS is an autoimmune disease that decreases blood flow and raises the risk of blood clots (including deep vein thrombosis), stroke, and pulmonary embolism. People diagnosed with APS often need to take blood thinners to lower the risk of blood clots. 

Lupus

Systemic lupus erythematosus (lupus) is a chronic autoimmune disease in which the immune system attacks healthy parts of the body. It can affect any organ or tissue, including the skin.

Reaction to Medication

Medications including minocycline, amantadine, thrombolytic drugs, quinidine, catecholamines, and interferon can cause livedo reticularis.

Rheumatoid Arthritis

Rheumatoid arthritis may cause LR-mottled skin because immune system problems that damage blood vessels can also affect the skin.

Pancreatitis

Mottled skin is a rare secondary symptom of both acute and chronic pancreatitis.

Thyroid Disease

The thyroid produces hormones that help regulate many functions in the body. Hormonal imbalances seen in thyroid disease may cause blood vessels to calcify which in turn leads to LR. Skin mottling may clear once hormone levels are corrected.

Covid-19

Livedo reticularis has been associated with COVID-19, both as an early symptom and as the only symptom of presumed infection. Although the cause of LR is unknown, most of the livedo reticularis-like lesions associated with COVID-19 tend to be mild and temporary.

End-of-Life

For those at the end of life, hands and feet may start looking purplish, blotchy, or mottled as blood circulation is compromised. Skin changes may move slowly up the arms and legs. 

What Are the Symptoms of Livedo Reticularis?

With physiologic livedo reticularis, the only symptom is a reddish-purplish skin discoloration that:

• Is web-like
• Forms numerous circular patterns on the skin
• Is most common on the arms and legs
• Has circular formations that tend to be complete with some broken segments
• Has pale centers within the circles
• Has no lumps or bumps, or associated pain

With pathological livedo reticularis, the symptoms may be identical to those seen with physiologic livedo reticularis. However, when livedo reticularis is caused by a serious underlying medical problem, the pattern of discoloration is often atypical. In addition:

• The color of the affected skin is often strikingly violet.
• It is more likely to form a highly irregular pattern of broken circles.
• Skin changes may be more widespread, and in addition to the arms and legs, appear on the trunk and buttocks, and may even become generalized.
• A painful nodule or an ulcer may be present in the center of the circular patterns.
• The skin discoloration tends to be permanent.
• It is often not noticeably associated with cold temperatures.

How Is Livedo Reticularis Diagnosed?

The diagnosis of livedo reticularis itself is usually straightforward, given the distinctive appearance of this condition 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.

Livedo Reticularis Differential Diagnosis

The diagnosis can become challenging if the skin discoloration, or the circumstances in which it appears, suggest a pathological cause. In these cases, the doctor will begin with a thorough medical history and physical examination.

Targeted diagnostic testing may be done to look for the suspected underlying condition.

If the initial evaluation does not point in a particular direction, the doctor may also order:

• Screening blood tests, such as a complete blood count and a metabolic panel
• Blood tests that screen for cold agglutinins, antiphospholipids, cryoglobulins, cryofibrinogens, autoimmune disease, and coagulation disorders
• A computerized tomography (CT) scan or magnetic resonance imaging (MRI) scan, if cancer is suspected
• A skin biopsy

How Is Livedo Reticularis Treated?

Physiologic livedo reticularis is a normal, passing phenomenon that has no known medical consequences. Aside from warming up the skin or reducing stress, physiologic livedo reticularis is not something to worry about and no treatment is required.

Because the underlying medical conditions associated with pathological livedo reticularis tend to be serious and potentially life-threatening, treatment should be aimed at addressing the underlying cause, once confirmed.

How Is Livedo Reticularis Prevented?

Preventing livedo reticularis may not always be possible. Taking steps to stay warm and boost blood flow may help for some.

• Regular exercise helps improve circulation. If your lifestyle or job is sedentary, start a habit of standing and stretching every 20-30 minutes during the day. For those with limited mobility, clenching hands, wiggling toes, gently rocking the head from side to side, and elevating the feet may prove beneficial.
• Keep warm by wearing multiple layers and covering up with a blanket or throw when you feel chilly. Be mindful of cold weather and dress appropriately for the temperature (e.g., gloves and warm footwear).
• Avoid pressure on arms or legs for long periods. Try to avoid crossing your legs, leaning on one arm for too long, or wearing tight clothes or footwear.
• Get a massage regularly. Massage can help significantly improve circulation. Find a massage therapist or learn some self-massage techniques.

• Stay hydrated. Drinking enough fluids (especially water) helps support good blood flow.
• Try to reduce stress. Even minor stress causes the body to release hormones that narrow blood vessels and restrict blood flow.

• Quit smoking. Smoking damages blood vessels and causes narrowing. Quitting can lead to significant improvements in your health regardless of how long you have smoked.

When to See a Healthcare Provider

You should see a healthcare provider if you have any of the signs or symptoms of livedo reticularis. This is especially important if:

• Warming up your skin or reducing stress does not improve skin discoloration.
• You have painful lumps.
• You are experiencing other symptoms or have a known underlying health condition.

Summary

Livedo reticularis is most typically a common, benign, and transient skin discoloration associated with cold exposure or stress. 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.