livedo reticularis

differentials

• Physiologic livedo reticularis, or cutis marmorata
  • can occur when blood vessels constrict in response to the cold. 
  • As the skin warms up, the blood vessels open again, which leads to the mottled skin clearing up. 
  • This can affect both adults and children, but it is more common in children and young wome
  • Occlusion of vessels may occur because of a hypercoagulable state.
    • This may present as blue toe syndrome.
    • Antiphospholipid syndrome (APS, also known as lupus anticoagulant syndrome) is characterised by blood clots due to sticky platelets. It results in livedo racemosa in 25% of patients, and 70% of those with SLE-associated APS.
    • Sneddon syndrome is an association of livedo racemosa with stroke in young adult women.
    • Livedoid vasculopathy is associated with ulceration due to fibrinolytic abnormalities and microcirculatory thrombosis.
    • Lymphocytic thrombophilic arteritis
    • Cryoglobulinaemia (immune globulins that precipitate in the cold)
    • Polycythaemia rubra vera (excessive number of red cells) or thrombocythaemia
    • Multiple myeloma
    • Cold agglutinin disease
    • Protein C and S deficiency
    • Antithrombin III deficiency
    • Disseminated intravascular coagulation
    • Haemolytic uraemic syndrome
    • Deep venous thrombosis
  • Autoimmune/vasculitis/connective tissue disease
    • Small, medium and large vessel vasculitis is associated with livedo racemosa.
    • Systemic lupus erythematosus
    • Dermatomyositis
    • Rheumatoid arthritis
    • Polyarteritis nodosa
    • Granulomatosis with polyangiitis
    • Temporal arteritis
    • Sjögren syndrome
  • Neurological disease
    • Reflex sympathetic dystrophy
    • Multiple sclerosis
    • Parkinson disease
    • Infection
    • Tuberculosis
    • Syphilis
    • Mycoplasma pneumonia
    • Viral infection, such as parvovirus, hepatitis C
    • Bacterial sepsis, such as meningococcal disease, streptococcal disease
    • Rheumatic fever (erythema marginatum)
  • Malignancy
    • Renal cell carcinoma
    • Inflammatory breast cancer (carcinoma erysipeloides)
    • Lymphoma (mycosis fungoides)
    • Acute lymphocytic leukaemia
  • Drugs
    • Amantadine (dopamine agonist used to treat Parkinson disease, multiple sclerosis, and attention deficit hyperactivity disorder) causes livedo through arteriolar vasospasm associated with depletion of catecholamines. Drug-associated livedo has also been reported with:
    • Minocycline
    • Gemcitabine
    • Catecholamines
    • Non-steroidal anti-inflammatory drugs.
  • Other
    • Cholesterol emboli and homocystinuria
    • Septic emboli
    • Hypercalcaemia (calcium deposits)
    • Thromboangiitis obliterans (Buerger disease)
    • Intra-arterial injection (especially in drug addicts)
    • Pancreatitis
    • Primary fibromyalgia
    • Congenital hypogammaglobulinaemia