Derm: Livedo reticularis: Free MSRA Podcast

🩺 FREE MSRA PODCAST – Livedo Reticularis: The Clue Beneath the Skin
Get the high-yield facts on livedo reticularis: the net-like, purplish skin pattern that can be a signpost to something much deeper. Perfect for your MSRA revision.

Key Learning Points

🔎 Definition
• Livedo reticularis is a vascular pattern: mottled, net-like purplish discolouration of the skin
• Most visible on limbs, worsens with cold

⚖️ Causes
• Primary (idiopathic): Benign, no underlying disease
• Secondary: Linked to serious conditions (systemic lupus erythematosus, antiphospholipid syndrome, polyarteritis nodosa, cryoglobulinaemia, vasculitis, medications, cold, clotting disorders)

🧬 Pathophysiology
• Arteriolar constriction/sluggish blood flow leads to deoxygenated blood pooling in superficial venules
• Can be due to vessel spasm, inflammation, clots, or abnormal proteins blocking flow

🩺 Clinical Features
• Lace-like, purplish (sometimes reddish-blue) network on skin
• Symmetrical, most common on legs and arms
• Pattern accentuated by cold; may fade with warmth
• No pain/itch unless underlying disease

🧠 Mnemonic: “NET CLASP” for Causes
N: None (idiopathic)
E: Endocrine/autoimmune (SLE)
T: Thrombotic (APS)
C: Cold
L: Lupus/vasculitis
A: Antiphospholipid syndrome
S: Systemic diseases
P: Polyarteritis nodosa/Proteins (cryoglobulinaemia)

🧪 Differential Diagnoses
• Cutis marmorata (transient in infants)
• Acrocyanosis (bluish extremities, no net pattern)
• Livedoid vasculopathy (painful, ulcerative)
• Embolic phenomena (acute, localised changes)

🔬 Diagnosis
• Clinical examination of skin pattern
• Investigate for secondary causes if red flags: full blood count, autoantibodies (ANA, anti-dsDNA), clotting screen, inflammatory markers
• Skin biopsy if uncertain or systemic disease suspected

💊 Management
• Primary: Reassure, keep warm, protect from cold
• Secondary: Treat underlying cause—immunosuppression (e.g., for lupus/vasculitis), anticoagulation (for APS), supportive care
• Regular follow-up for systemic disease

⚠️ Complications
• Primary: Benign, cosmetic only
• Secondary: Depends on underlying condition—risk of ulceration, tissue damage, stroke or thrombosis (in APS), organ involvement (vasculitis, lupus)

📚 MSRA Revision Resources for Livedo Reticularis
📝 Revision Notes: https://www.passthemsra.com/topic/livedo-reticularis-revision-notes/
💬 Flashcards: https://www.passthemsra.com/topic/livedo-reticularis-flashcards/
🧠 Accordion Q&A: https://www.passthemsra.com/topic/livedo-reticularis-accordion-qa-notes/
🚀 Rapid Quiz: https://www.passthemsra.com/topic/livedo-reticularis-rapid-quiz/
🧪 Full Quiz: https://www.passthemsra.com/quizzes/livedo-reticularis/
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Episode Transcript

(00:00):
OK, picture this, you see someone's skin, maybe their
legs, their arms, and it's got this, this weird kind of web
like purplish reddish blue pattern, almost like a net or or
lace. And it definitely seems worse
when they're cold. Have you seen that?
I mean maybe you know, read about it while revising for

(00:20):
something like the MSRA. Yes, that distinctive pattern,
it's got a name and it's definitely more than just how
the skin looks. It's called Lividoriticularis.
Lividoriticularis, right? And you're spot on recognising
it is, well, it's pretty important in clinical practise
and yeah, definitely something that could pop up in exams.
Exactly. So today we're doing a deep dive

(00:42):
into lividoriticularis. We're kind of working from a set
of revision notes, boiling them down, making the really high
yield for your studies. That's the plan.
We want to break this condition down into those key points you
need for revision. Turn the the core facts into a
clear overview. Highlight what's really
important, especially for exam questions, because focusing on
one thing like this lets us really build up a structured

(01:05):
understanding what it is, why ithappens, what else it could be,
and crucially, what you do aboutit.
Yeah, I'm keen to get into this because it sounds like one of
those things that seems simple, just a skin pattern, but it
could actually be pointing towards something, well,
something bigger going on. Absolutely.
That's exactly why it's a good revision topic.
The skin, you know, it's often like a window and Lavetta

(01:27):
reticulars is a perfect example.The key is understanding the
why. Why is that pattern there?
What could be causing it? OK, let's unpack it then.
Starting right at the beginning,what is Livido reticularis?
How would you describe that look?
OK, so at its heart it's a description, a visual finding.
It's that modelled net like pattern on the skin, right Then

(01:47):
that yeah, the colour is typically purplish or maybe
reddish blue, and you usually see it on the limbs, arms, legs.
It really does look like a sort of Lacy network under the.
Skin and why? What's actually happening in the
skin to make it look like that? Like a net.
It's all about blood flow, specifically in the tiny blood
vessels of the skin, the arterioles and the venules.

(02:10):
Think of them like a network of tiny branching pipes with livero
reticularis. The little arteries, the
arterioles, they constrict, theynarrow down, and that narrowing
disrupts the normal flow. Blood flow gets sluggish in
those areas where the pipes are narrower and it tends to pull a
bit or slow down in the connected venules.
So the. Blood's not moving smoothly.
Exactly. It's sluggish, and because it's

(02:31):
moving slower, more oxygen gets pulled out of the blood in those
areas, right? And deoxygenated blood looks,
well, purplish or bluish. So that deoxygenated blood shows
through the skin where those arterioles are constricted,
creating that net pattern, the paler bits in between or where
the flow is, you know, relatively better.
That pipe analogy helps some Pikes.

(02:51):
Narrowed flow slows down and thecold makes it worse because,
well, cold makes blood vessels constrict anyway.
Precisely. Cold triggers vasoconstriction
naturally to save heat. In levera reticularis, that
tendency is already there or exaggerated, so the cold just
makes the pattern stand out muchmore.
OK, and this leads us to something absolutely fundamental

(03:15):
you need to grasp. Levator reticularis can be
primary or secondary. Primary versus secondary, that's
the big split. That's the crucial distinction,
yes. Primary levator reticularis is
when you see the pattern, but even after checking, you can't
find any underlying medical reason for it.
It's often just there, benign, sometimes runs in families.
OK, secondary levator reticularis though, that that

(03:36):
means the pattern is a symptom. It's a sign of another medical
condition going on underneath. It's the one you really need to
worry about. Well, that's the one you need to
investigate thoroughly because those underlying conditions
often need specific treatment. Recognising it could be
secondary is vital. Right.
So if it is secondary, what kindof conditions are we talking
about? What are the root causes?
The aetiology? OK, so the list of secondary

(03:59):
causes is quite varied, and for exams you really need to know
the common important ones. While primary, the idiopathic
type with no known pause is probably the most common type
overall, the real clinical significance comes from those
secondary causes. And the high yield list for
revision includes. Right key secondary causes,
definitely. Connective tissue diseases like

(04:21):
systemic lupus erythematosus SLE.
That's a classic link Lucas. Then vasculitides, inflammation
of blood vessels, particularly polyarteritis nidosa or pan pan
conditions affecting blood clotting like anti phospholipid
syndrome. APS.
That's another really important one.
APS, right. And then there are others may be
less common but still notable like cryoglobulinemia, Ehlers

(04:43):
Danlos syndrome, homocystinuria.It's quite.
A list, definitely a list to remember linking that skin
pattern to these specific diseases.
And I guess that list pretty much tells you the risk factors
too. Exactly right.
The risk factors for libeto reticularis are mostly the risk
factors for those underlying conditions.
So if someone has a history, personal or family of autoimmune

(05:06):
disease, connective tissue disorders, clotting problems,
vasculitis, those are big risk factors.
Also, certain medications or even things like cold exposure
in some contexts can be linked to secondary forms.
You know, if you see lavetta reticularis in someone who's
had, say, multiple miscarriages or blood clots.
You think APS straight away? Anti phospholipid syndrome
should be very high on your list.

(05:27):
Yes, it connects the dots. OK, this is where it gets really
interesting, understanding the why beyond just constriction.
Let's dig a bit deeper into the pathophysiology.
How does the underlying disease in secondary cases actually
'cause that blood vessel problem?
Good question. So the basic mechanism is still
that arterial constriction leading to sluggish flow and
that visible deoxygenation. But why the vessels constrict or

(05:51):
the flow gets disrupted? That varies in primary livido
reticularis. It might just be a functional
thing, maybe the autonomic nerves controlling the vessel
tone or a bit dysregulated. But in the secondary ones.
In secondary cases the underlying disease is actively
interfering. For example, in vasculitis like
PAN, you get inflammation that directly damages the vessel

(06:12):
walls. That damage can cause narrowing
or even blockages. In anti phospholipid syndrome,
those auto antibodies make the blood sticky, prone to clotting.
Tiny clots can form in these skin vessels, blocking flow.
Actual clots, yeah. Or in cryoglobulinemia, abnormal
proteins clump up in the cold and physically block the

(06:33):
vessels. In lupus, you might get immune
complexes depositing in the vessels, causing inflammation
and disrupting flow. So lots of different ways to get
to the same result. Pretty much the visual effect.
That net pattern from sluggish deoxygenated blood looks
similar, but the process causingit is tied to the specific
underlying disease. It all comes back to messing up
the flow in that branching network.

(06:54):
Got it. So you see this net like
pattern. What else might it be?
What are the main differential diagnosis to keep in mind?
Crucial point for exams and practise.
You need to be able to distinguish Lovato reticularis
from a few other things. Key differentials would be cutus
mammarata, acrocyanosis, lovedoid vasculopathy, and maybe
embolic phenomena. Any quick ways to tell them

(07:17):
apart? Pointers.
Yeah, there are features to lookfor, though sometimes it needs
more investigation. Cutus mammarata.
That's and physiological really common in babies and it's
usually transient. It vanishes quickly when the
skin warms up. Right levator reticularis is
more persistent. Generally, yes.
It improves with warmth, but often doesn't disappear
completely. Accuracyanosis is different.
Again, that's more persistent. Symmetrical blueness, usually

(07:39):
just hands and feet. Also worse than cold, but it
lacks that distinct widespread net pattern.
OK. Levdhoid masculopathy often
comes with painful ulcers, whichlevator reticularis itself
doesn't usually cause an embolicphenomena.
That's usually sudden, localised, painful colour
changes much more acute than thediffuse pattern of LR.
So think transient versus persistent location, knit

(08:02):
pattern versus just blue ulcers or not sudden onset versus
gradual. That helps clarify things.
Now what about epidemiology? How common is this and who tends
to get it? Well, the exact prevalence like
here in the UK isn't really known.
It can show up at any age really, from infants though
that's often cutest marmarata right up to older adults.

(08:23):
OK, but secondary lovetto reticularis, the one linked to
other diseases, that's more typically seen in adults, and
its prevalence depends entirely on how common those underlying
causes are, right? And importantly, like many
autoimmune conditions, secondaryLR linked to diseases like lupus
is seen more often in women. So age and sex can sometimes
give you a clue pointing towardsthose autoimmune possibilities.

(08:45):
And let's just loop back to the clinical features one more time
to really nail down what you seeand what might come with it.
The hallmark signs. The absolute hallmark, as we've
said, is that distinctive, persistent, modelled or net like
pattern, purplish or reddish blue, most often on the limbs,
arms, legs, sometimes hands and feet.
And it definitely gets worse with cold.

(09:05):
Characteristically worse with cold, yes, and it might fade a
bit with warming, but usually the pattern stays somewhat
visible, unlike that transient cutis marmarata.
Are there other symptoms that goalong with it?
Pain. Itching.
This is a really key point. Levator reticularis itself is
mainly a skin sign, a physical finding.

(09:26):
It doesn't inherently cause painor itch or anything like that.
But if it's secondary levator reticularis, the person will
often have other symptoms, symptoms of the underlying
condition. OK, so things like joint pain,
maybe fatigue like an SLE or systemic stuff like fever,
weight loss, maybe with vasculitis, symptoms of poor
circulation or clotting if it's APS.

(09:48):
So if someone has the skin pattern plus other significant
symptoms. Red flag for a secondary cause.
Absolutely. Your suspicion for an underlying
systemic cause should go way up.OK.
So you see the pattern, you takethe history, maybe there are
other symptoms you suspect it could be secondary.
How do you investigate? How do you find that 'cause?
Right, The investigation isn't really for the levator
reticularis itself. It's using LR as a clue to hunt

(10:10):
for the underlying problem. So it needs a pretty
comprehensive evaluation tailored to what you suspect
based on everything else. What are the main steps?
Tests. Always starts with a really
detailed history asking about all those systemic symptoms,
autoimmune features, clotting history, family history, and a
thorough physical exam looking for other signs.
OK, then you move to tests. Labs are fun, fundamental,

(10:33):
you'll likely do a full blood count, looking for anaemia, low
platelets, maybe coagulation profile screening for clotting
issues, and crucially auto antibody testing if you're
thinking autoimmune. Like Ana?
Exactly, Ana is a common starting point.
If that's positive you might go for more specific ones like anti
DSDNA or anti melisim for lupus.Depending on the picture you'd

(10:54):
also check inflammatory markers,ESR, CRP which can be up in
vasculitis or autoimmune diseases.
So the tests depend on the symptoms and history again.
Totally guided by the clinical picture.
You might also consider imaging maybe a Doppler ultrasound to
check blood flow if you suspect clots, or even angiography in
rare cases if you're thinking about larger vessel vasculitis.

(11:15):
And biopsy. Sometimes, yes, a skin biopsy
can be really helpful. It lets the pathologist look
directly at the small blood vessels in the skin.
They can see inflammation, vasculitis, tiny clots, maybe
deposits related cryoglobulins. It helps confirm what's going on
at the vessel level. Let's try quick revision
scenario. Say a 35 year old woman comes

(11:36):
in. She has this levator reticularis
pattern. You ask more and she mentions
recurring joint pain. She's tired all the time and
gets rashes in the sun. Based on that age, sex, skin
patterns, symptoms, what investigations jump to mind
first? OK yeah that picture screams
possible connective tissue disease, especially lupus SLE.
So top of the list would be those autoimmune blood tests,

(11:57):
Ana definitely, probably anti DSDNA, maybe anti E system.
Also check inflammatory markers like ESR, CRP, full blood count
for anaemia or low platelets. And you'd want to check kidney
function too as lupus often affects the kidneys.
It shows how the whole picture points you towards specific
tests. That really helps clarify it.
So you've done the work up, you know if it's primary or

(12:19):
secondary, what's the managementplan?
It completely depends on that primary versus secondary
distinction. If it's primary levator
reticularis, no underlying causefound, no other symptoms, then
generally it's about reassurance.
Nothing needs to be done medically.
Usually not. It's considered benign cosmetic.
The main advice is practical, protect the skin from cold, keep

(12:39):
warm as that can make it less noticeable.
And if it's secondary? If it's secondary, the whole
focus shifts. You absolutely must treat the
underlying condition. You're not treating the skin
pattern directly, you're treating the disease causing it.
The meds depend on the disease. Exactly, if it's lupus or
vasculitis you'll be looking at immunosuppressants, maybe
steroids, other disease modifying drugs.

(13:00):
If it's anti phospholipid syndrome causing it then the
treatment is anticoagulation to prevent clots.
It's all about tackling the rootcause.
Does treating the cause make theOlivito pattern go away?
Often yes, treating the underlying disease can lead to a
big improvement. Sometimes it resolves
completely, but not always. Sometimes the pattern can
persist even if the disease is under control.

(13:22):
So symptomatic advice, keeping warm, avoiding cold,
moisturising that's still helpful and regular follow up is
key to monitor the underlying condition.
Another quick scenario. Then patient gets diagnosed with
livatoreticularis. Workup confirms it's secondary
to anti phospholipid syndrome. They have the antibodies.
Maybe a history of clots? Based on what you just said,
what's the absolute cornerstone medication you'd expect them to

(13:44):
be on? For anti phospholipid syndrome,
without a doubt it's anticoagulation.
You'd fully expect that patient to be on warfarin or perhaps one
of the newer direct oral anticoagulants.
That's to prevent those dangerous blood clots.
The main risk in APS that link LR plus APS equals
anticoagulation is super high yield.

(14:05):
Got it, great connection. Lastly, then prognosis, what's
the outlook and what complications should we be
aware? Of OK prognosis, just like
management, hinges on the type. Primary libeto reticularis
generally excellent prognosis. It's benign, doesn't progress,
doesn't usually cause complications itself.
It's more of a cosmetic nuisancethat might stick around and

(14:26):
secondary For secondary LR, the prognosis is tied entirely to
the underlying cause. How severe is it?
How well can it be treated? If you catch the underlying
disease early and manage it effectively, the outlook is much
better. The libeto might improve, but
the overall prognosis depends oncontrolling that systemic
disease. And complications, Do they come
from the skin pattern itself? Almost entirely no.
The serious complications linkedwith levator reticularis come

(14:48):
from the underlying conditions causing the secondary form such
as well. Uncontrolled autoimmune diseases
or vasculitis can damage organs,kidneys, heart, lungs, brain.
Clotting disorders like APS carry that significant risk of
major clot stroke. DVTPE.
I thought I recalled something about levator reticularis itself
being linked, maybe rarely, to clot risk.

(15:10):
Yes, it's worth mentioning, but keep it in context.
There is some suggestion, yeah, that very persistent levator
reticularis might rarely indicate a slightly higher
tendency for tiny clots in the skin vessels.
But the overwhelming risk of serious clots comes when LR is a
symptom of a known underlying clotting disorder like APS.
So focus on the underlying causefor risk.

(15:32):
Definitely managing the underlying condition is the key
way to cut down the risk of serious complications.
OK, so let's wrap this deep diveup.
Levito reticularis, that cold sensitive net like purplish skin
pattern. The absolute key takeaway for
exams and practise is distinguishing primary, which is
generally benign, from secondarybecause secondary LR acts like a

(15:52):
potential signpost, a clue pointing towards a whole range
of possibly serious underlying issues, Autoimmune diseases,
vasculitis, clotting disorders. Precisely recognising the
pattern is step one. Step 2 is knowing it could mean
something systemic is going on, remembering that high yield list
of secondary causes and knowing how to investigate based on the

(16:14):
whole clinical picture. That's vital for anyone revising
for exams like the MSRA. So what's the big picture here?
It really makes you think, doesn't it?
How something that just looks like your skin reacting a bit
oddly to the cold could actuallybe the very first sign, that
first visible hint of a serious condition affecting the whole
body. It just underlines how the skin
can be this amazing window into our overall health.

(16:36):
It really can. A powerful reminder.
For more free MSRA revision resources, do visit
freem-sra.com and for the full Premium Revision toolkit you can
head over to pass the m-sra.com.