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These conditions are characterized by vascular occlusion without frank vasculitis.


1. Livedo reticularis (livedo racemosa)
Livedo reticularis is seen most often on the legs. The mottled, reddish purple, reticulated
discoloration reflects the sluggish vascular flow in the superficial dermis. A continuous
livedo network is likely to be physiological and will disappear when the skin is warmed.

A broken (discontinuous) persistent livedo reticularis is seen with:
• Hyperviscosity states: polycythaemia rubra vera, antiphospholipid syndrome.
• Medium- or large-vessel vasculitis: connective tissue diseases, PAN, GPA.
• Cholesterol emboli and other emboli; calciphylaxis.

What should I look for?
• A mottled, reddish purple, reticulated discoloration, usually on the limbs.
• Retiform purpura (purpura in a reticulate or net-like distribution).
• Is the skin cold? does the discoloration disappear when the skin is warmed, indicating a
physiological change of no significance?
• Is the discoloration a continuous network or discontinuous?
• Signs of a vasculitis affecting medium or large cutaneous vessels, e.g. subcutaneous
nodules or ulcers.

Differential diagnosis
• Erythema ab igne, a reticulated brown staining that can develop if the skin is exposed
chronically to heat from a radiator, open fire, or hot water bottle.

What should I do?
• If the livedo is physiological, no investigation or treatment is required.
• If the livedo is discontinuous and persistent:
o Screen for an underlying disease (see earlier in this section).
o Take deep biopsies that extend into fat to demonstrate diagnostic pathology in
arterioles or small arteries such as cholesterol emboli or hyaline thrombi.

Livedoid vasculopathy with ulceration
Synonyms: segmental hyalinizing vasculitis, livedo reticularis with summer/winter
ulceration, livedoid vasculitis.
This thrombo-occlusive vasculopathy affects young to middle-aged women. Hyaline
thrombi occlude small vessels in the upper and mid dermis, leading to painful ulceration
that is chronic and recurrent

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