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ULY CLINIC

18 Septemba 2025, 12:08:56

Mottled skin

Mottled skin refers to patchy, reticulated discoloration resulting from primary or secondary changes in the deep, middle, or superficial dermal blood vessels. It may appear reddish-blue or violaceous and is often described as livedo or cutis marmorata.Although sometimes a benign physiologic response to cold, mottling can also indicate impaired tissue perfusion or serious systemic disease.

Pathophysiology

Vascular tone changes: Vasospasm of mid-dermal arterioles slows flow through dilated superficial venules and capillaries, producing a net-like reddish-blue pattern (livedo reticularis).
Reduced perfusion: Arterial obstruction or systemic vasoconstriction limits oxygenated blood delivery, resulting in pallor and cyanotic patches.
Shock states: Sympathetic outflow and circulating catecholamines shunt blood away from skin toward vital organs.
Deposition or inflammation: Immune complexes, cryoglobulins, or arteritis can damage vessel walls, causing patchy necrosis and mottling.

History and Physical Examination

History

Time of onset (sudden vs gradual), duration, and precipitating factors (cold exposure, immobility, trauma).
Associated symptoms: limb pain, numbness, tingling, weakness, abdominal pain, fever, weight loss, bleeding, or systemic symptoms.
Past history: peripheral arterial disease, vasculitis, connective-tissue or hematologic disorders, smoking, medication exposure.

Physical Examination

Inspect color, distribution, and symmetry (localized vs generalized).
Palpate temperature, skin texture, and presence of tenderness or nodules.
Assess perfusion: capillary refill, distal pulses, limb swelling, hair distribution, muscle bulk.
Check neurologic function: motor strength, sensation.
Examine mucosa, abdomen, and other organ systems if systemic disease suspected.

Medical causes

Cause	Onset	Key Features	Associated Signs	Pathophysiology	Management
Acrocyanosis	Chronic/intermittent	Persistent symmetrical blue-red mottling of hands/feet/nose, worse in cold or anxiety	Usually painless, hands/feet cold	Vasospasm of small cutaneous arterioles	Keep warm, avoid smoking/stress
Acute arterial occlusion	Sudden	Pale → blotchy cyanosis/livedo; demarcation at obstruction	Severe limb pain, paresthesia, paresis, coolness, absent pulses	Embolus or thrombosis halts arterial inflow	Immediate vascular surgery or thrombolysis
Arteriosclerosis obliterans (PAD)	Gradual	Leg pallor/cyanosis, livedo	Claudication, diminished pedal pulses, cool extremities	Atherosclerotic lumen narrowing	Smoking cessation, exercise, antiplatelets, revascularization
Buerger’s disease	Subacute/chronic	Asymmetrical mottling, livedo along vessels	Intermittent claudication, distal ulcers, neuropathy	Segmental vasculitis, strongly tobacco-related	Complete smoking cessation, vasodilators, surgery if critical
Cryoglobulinemia	Variable	Patchy livedo, petechiae, purpura	Fever, urticaria, ulcers, Raynaud’s, renal/ocular bleed, gangrene	Immune complexes precipitate at low temp → vessel occlusion	Treat trigger (e.g., hepatitis C), corticosteroids, plasmapheresis
Hypovolemic shock	Acute	Early mottling at knees/elbows → generalized	Pallor, cool clammy skin, tachycardia, hypotension, oliguria, confusion	Catecholamine vasoconstriction in low circulating volume	Rapid IV fluids/blood, oxygen, monitor perfusion
Idiopathic livedo reticularis	Chronic/intermittent	Symmetrical net-like mottling, esp. on legs/buttocks; accentuated by cold	Usually asymptomatic	Reversible vasospasm of dermal arterioles/venules	Warmth, reassurance
Polyarteritis nodosa	Subacute	Asymmetric patchy livedo; tender nodules	Fever, weight loss, neuropathy, ulcers, gangrene	Necrotizing vasculitis of medium arteries	High-dose corticosteroids, immunosuppression
Polycythemia vera	Gradual	Livedo, rubor, purpura	Headache, dizziness, pruritus, visual disturbance	Increased RBC mass → sluggish flow, thrombosis	Phlebotomy, cytoreductive therapy
Systemic lupus erythematosus	Chronic/relapsing	Livedo (outer arms/legs)	Butterfly rash, arthritis, Raynaud’s, alopecia, seizures	Immune complex vasculitis	Immunosuppressants, antimalarials
Thermal injury (erythema ab igne)	Gradual	Local brown-red reticulated mottling	History of heat exposure (hot bottle/heating pad)	Persistent mild heat damages dermal vessels/pigment	Remove heat source, monitor for malignancy
Immobility/dependency	Hours-days	Bluish mottling of dependent areas	Occurs in bedridden pts	Venous stasis	Frequent repositioning, skin care

Emergency interventions

Generalized mottling with pallor, clamminess, tachycardia, hypotension → treat as shock:
- Place supine, elevate legs 20–30°.
- Give high-flow oxygen, establish large-bore IV for fluids/blood.
- Start cardiac and urine output monitoring; prepare for central access or pulmonary artery catheter.
Localized mottling with pain, numbness, coolness, absent distal pulses → suspect acute arterial occlusion:
- Keep limb dependent and at room temperature.
- Start IV in an unaffected limb, obtain urgent vascular imaging, prepare for embolectomy or bypass.

Special considerations

Mottling is often chronic; definitive management targets the underlying disorder.
Monitor perfusion and tissue viability if mottling accompanies pain, pallor, or pulselessness.
Avoid tight clothing, cold exposure, and prolonged pressure on extremities.

Patient counseling

Explain possible causes (from benign cold response to vascular occlusion).
Educate about warning signs: sudden pain, numbness, skin ulceration, or systemic symptoms.
Encourage smoking cessation, regular exercise, and optimal control of vascular risk factors.

Pediatric pointers

Cutis marmorata is common in newborns/infants exposed to cold and usually benign.
Mottling with lethargy or poor perfusion may indicate shock or sepsis.
Evaluate for congenital heart disease or severe dehydration if persistent.

Geriatric pointers

Elderly patients develop mottling easily due to reduced perfusion.
Consider bowel ischemia in older adults with livedo reticularis plus abdominal pain or bloody stool.
Peripheral arterial disease and polycythemia vera are common in this age group.

References

Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 7th ed. Elsevier; 2021.
James WD, Elston DM, Treat JR, et al. Andrews’ Diseases of the Skin: Clinical Dermatology. 13th ed. Elsevier; 2020.
Long B, Koyfman A. Mottled skin in the emergency department: pearls and pitfalls. J Emerg Med. 2018;54(3):348-356.
Rook A, Burns T, Breathnach S, Cox N, Griffiths C, eds. Rook’s Textbook of Dermatology. 9th ed. Wiley-Blackwell; 2016.
Tintinalli JE, Ma OJ, Yealy DM, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill; 2020.
Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. American Academy of Pediatrics; 2012.
Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. Mosby Elsevier; 2008.
McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Mosby Elsevier; 2010.
Sommers MS, Brunner LS. Pocket Diseases. F.A. Davis; 2012.