People typically use the phrase “mottled skin” to describe livedo reticularis, a condition that causes a blotchy or web-like pattern of red, blue, or purple lines to appear across the skin. In very deep skin tones, the pattern may be dark brown.
Because “mottled skin” is not a medical term, people may also use this to describe a number of other skin conditions and rashes. This article will focus on mottled skin caused by livedo reticularis.
Many things can reduce the flow of oxygenated blood to the skin, so many things can cause livedo reticularis. Doctors sort cases into different categories to make it easier to understand the potential cause.
First, they determine whether the rash is associated with systemic symptoms. From there, they break cases down into subcategories:
- Physiologic: This type of mottled skin appears only when someone becomes cold. It improves when a person warms up. Another name for this is cutis marmorata.
- Primary: Primary livedo reticularis also comes and goes, but not in response to cold temperatures. It is not associated with an underlying condition.
- Secondary: This is when livedo reticularis is the result of another condition. This could include an infection, neurologic disease, endocrine disease, vasculitis, or connective tissue disorder, among others. Secondary livedo reticularis can also occur due to medications, such as amantadine.
- Idiopathic: This type of livedo reticularis is consistent and does not go away. It has no other symptoms associated with it and no clear cause. Rarely, it is an early symptom of an autoimmune condition known as antiphospholipid syndrome (APS) or Sneddon’s syndrome, but it is not usually harmful.
- Livedo racemosa: If the rash is associated with systemic symptoms, doctors must check whether the rash is livedo reticularis or livedo racemosa, a related condition that also causes mottling. Livedo racemosa is always the result of another condition and is strongly associated with APS.
Below are a few of the conditions associated with mottled skin.
Physiologic livedo reticularis is a harmless condition that causes mottled skin to develop when a person experiences cold temperatures. It is also known as cutis marmorata.
Cutis marmorata is
This condition does not require treatment. People can reduce their symptoms by warming their skin.
- unexplained weight gain
- low energy
- sensitivity to cold
Hyperthyroidism may cause:
- unexplained weight loss
- heart palpitations or an unusually fast heart rate
Diseases affecting the parathyroid gland may also cause mottled skin, especially when blood vessels calcify, damaging circulation.
Treatment for thyroid disease focuses on correcting a person’s thyroid hormone levels. People with hypothyroidism will need to take synthetic thyroid hormones, while those with an overactive thyroid may need medication that reduces activity in the thyroid.
Rheumatoid arthritis (RA) is another potential cause of mottled skin. It is an autoimmune disease that causes joint pain and inflammation. It may also cause dark, patchy, or mottled skin, which may be due to the way the inflammatory condition affects the blood vessels.
Other symptoms of RA include:
- low fever
- pain and stiffness that lasts for more than 30 minutes
- weight loss
- firm lumps or nodules beneath the skin in the hands, elbows, or ankles
There is no cure for RA, but treatment can reduce the symptoms and the risk of joint damage. Doctors can prescribe disease-modifying antirheumatic drugs, biologics, and pain medications to reduce autoimmune activity and manage the symptoms.
Some research suggests there is an association between livedo reticularis and COVID-19. A 2020 case study notes that skin symptoms may occur in as many as
Doctors do not know what specifically caused the rash in these cases. It may be part of an immune reaction, or it could be related to new medications for COVID-19.
Other symptoms of COVID-19
- new loss of taste or smell
- feeling short of breath
- body aches
- sore throat
- congested or runny nose
If someone could have COVID-19, they need to remain at home and seek testing from their local health authority, even if their symptoms are mild. Most cases of COVID-19 improve on their own without treatment, but people must seek emergency help if someone develops:
- difficulty breathing
- blue or white lips
- new confusion
- pain or pressure in the chest
- difficulty staying awake
APS, or Hughes syndrome, is an autoimmune condition that mostly affects young to middle-aged adults. It causes the body to make proteins that increase blood clotting. This can lead to dangerous clots throughout the body, increasing the risk of stroke and pulmonary embolism.
Mottled skin is a common symptom of APS, along with red or purple skin patches. A person may also develop:
- blood circulation problems
- blood clots
- leg ulcers
People who have APS have an increased risk of developing deep vein thrombosis. For this reason, many people with this diagnosis need blood thinning medications to help prevent dangerous blood clots.
- severe abdominal pain
Treatments for acute pancreatitis include IV fluids and anti-inflammatory medication. Lifestyle changes also may help prevent it from coming back.
Lupus is an autoimmune inflammatory condition in which the immune system begins attacking healthy tissue. If lupus causes damage to the small blood vessels, a person with this condition may develop livedo reticularis.
Other symptoms of lupus include:
- a butterfly-shaped rash on the face
- dry eyes
- breathing problems
Shock can be caused by:
- an accident or trauma
- blood loss
In addition to cold and mottled skin, symptoms of shock can include:
- difficulty breathing
- enlarged pupils
- rapid heart rate
- rapid breathing
If someone seems like they are in shock, contact emergency services immediately.
Treatment may include oxygen, IV fluids, and further testing. A person may also need treatment for the underlying cause of shock. For example, a severe infection may require IV antibiotics.
Mottled skin in newborn babies is usually the result of cutis marmorata. It is a typical physiological response to cold temperatures and does not require treatment. Babies will usually grow out of cutis marmorata in a few weeks or months, but it can persist into adulthood.
Rarely, persistent mottled skin in babies happens because of cutaneous marmorata telangiectatica congenita, a genetic condition that causes blood vessels to form differently than usual. It can be associated with other genetic conditions, such as Down syndrome, Adams-Oliver syndrome, Cornelia de Lange syndrome, or phakomatosis pigmentovascularis.
The skin may appear mottled when a person is close to dying, particularly if it affects the upper extremities. Other signs that someone may be approaching death include:
- trouble swallowing
- refusing food and water
- decreased or no urination
- being delirious or unconscious
- irregular breathing, such as not breathing for long periods of time or taking short, rapid breaths
- extreme fatigue or weakness
- reduced heart rate
- speaking with people who have died or seeing people who are not there
A person showing these signs usually only has a few days to a few weeks left. There is no treatment, but comfort measures may help. This can include talking to the person, holding their hand, keeping their lips moisturized, calm and soothing music, massage, elevating the head of the bed, and pain medication.
Mottled skin may persist after someone dies. This is because the heart stops pumping, so circulation stops.
People should speak with their doctor if they have mottled skin and are not sure why. A doctor may:
- perform a physical examination
- take a complete medical history
- request blood work to check for infections and illnesses
- perform a skin biopsy for further evaluation
A doctor will also ask when the symptoms appeared and whether there are other symptoms that might help explain the problem. For example, a person with an infection who seems confused may be in shock, while a newborn baby may have developmentally typical skin mottling.
Mottled skin is not always preventable, depending on what is causing it. But if someone has cutis marmorata or another condition that affects body temperature or circulation, taking steps to stay warm and boost blood flow may help.
People can try:
- Staying active: Regular exercise can help improve circulation. Avoid sitting or lying down for long periods of time, wherever possible. If this is unavoidable, take regular breaks to stretch and move around. People who have limited mobility may find it helpful to elevate their feet.
- Keeping warm: Wearing multiple, light layers of clothing is a more effective way to stay warm than wearing one thick layer. When sitting, it may help to keep the legs and feet warm if a person uses a blanket. Wear gloves before going outside in cold weather to trap warm air.
- Reducing pressure on the extremities: Try to avoid putting weight on the arms or legs for long periods. For example, if someone often sits with the legs crossed, they could try uncrossing them to allow blood to flow more easily. Wearing tight clothing may also reduce blood flow, so aim for clothes that fit but do not dig in.
- Massage: Massage can help stimulate circulation in the skin. A person can visit a professional for this or learn self-massage techniques.
Mottled skin is not harmful in itself. Some people develop this symptom when they are cold. Others have idiopathic livedo reticularis, which is when mottled skin occurs on its own and has no clear cause.
Sometimes mottled skin is a symptom of another condition. It is associated with thyroid disease, acute pancreatitis, and shock. If it is a sign of an underlying disorder, there will typically be other symptoms that occur alongside skin mottling.
People with mottled skin as a result of cold temperatures may be able to ease this symptom by boosting circulation and warming the skin. If warming the skin does not help, or mottled skin is unconnected to temperature, it is a good idea to speak with a doctor.