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Lupus Mottled Skin and the Symptoms

Lupus is a complex autoimmune disease affecting the skin and other body parts. Among the skin manifestations commonly associated with lupus is “mottled skin.” This is a condition where the skin appears patchy, discolored, and uneven.

Donald Thomas, MD author of The Lupus Encyclopedia for Gastrointestinal symptoms in lupus blog post

This blog on “Lupus Mottled Skin and the Symptoms” was edited and contributed to by Donald Thomas, MD; author of “The Lupus Encyclopedia.” Parts of this blog post come from “The Lupus Encyclopedia: A Comprehensive Guide for Patients and Health Care Providers, edition 2

In this article, we will explore the phenomenon of lupus-mottled skin, its symptoms, potential causes, and effective management strategies.

What is Lupus Mottled Skin?

Lupus mottled skin, also known as livedo reticularis, presents a skin condition characterized by a lacy, net-like pattern of reddish or bluish discoloration on the skin’s surface. These patches often appear in a symmetrical pattern on the arms, legs, and torso. Livedo reticularis most commonly affects the legs. The constriction of blood vessels near the skin’s surface causes discoloration, leading to reduced blood flow in those areas.

Symptoms of Lupus Mottled Skin

  1. Lacy Pattern: The defining characteristic of mottled skin is the intricate, lace-like pattern on the skin. It is more noticeable in colder temperatures.
  2. Color Changes: The patches can appear reddish or bluish, depending on the temperature and underlying cause.
  3. Temperature Sensitivity: The discoloration may become more pronounced in response to temperature changes, such as exposure to cold or hot weather.

Causes of Lupus Mottled Skin

Vascular Changes

Lupus can affect the blood vessels causing a reduction in blood flow and the condition is called livedo reticularis. Livedo reticularis is a rash caused by decreased blood flow in small blood vessels beneath the skin. It forms net-like areas of reddish or purplish discoloration, especially on the arms and legs. There’s usually no permanent scarring and it rarely causes significant problems.

It can be more noticeable during periods of stress and cold. People with livedo reticularis sometimes (but not always) are positive for antiphospholipid antibodies. People with antiphospholipid syndrome can develop livedo reticularis, as well as a more extreme example of livedo called livedo racemosa. If livedo reticularis occurs in someone with a stroke, it is called Sneddon syndrome. Sneddon syndrome is sometimes, but not always, due to antiphospholipid antibodies. (This section on livedo reticularis comes from The Lupus Encyclopedia, 2nd edition, chapter 8). The photo page of this website contains a photo of livedo reticularis on a lupus patient.

Vasculitis

If lupus causes actual inflammation of the blood vessels, it is called vasculitis. This inflammation can cause blood vessels to constrict and reduce blood flow, resulting in the mottled appearance of the skin.

Raynaud’s Phenomenon

Some individuals with lupus may also experience a condition called Raynaud’s phenomenon. This is where blood vessels in the extremities narrow in response to cold temperatures, leading to a similar mottled appearance.

Medications

Certain medications can cause mottled skin. Beta-blockers, amantadine, vasoconstrictors, and nonsteroidal anti-inflammatory drugs, and minocycline can cause livedo reticularis or mottled skin.

Livedoid Vasculopathy

This section comes from The Lupus Encyclopedia, 2nd edition, chapter 8: Livedoid vasculopathy is a rare cause of skin ulcers. Livedoid vasculopathy starts with a rash on the arms or legs that can look like livedo reticularis, hence the term “livedoid.” It is caused by an abnormality of the small arteries (vasculopathy) within the skin, causing reduced skin blood flow and painful ulcers, especially on the feet.

Management and Treatment

  1. Lifestyle Modifications: Avoiding extreme temperatures and protecting the skin from cold or harsh weather can help reduce the severity of mottled skin patches.
  2. Medication Adjustments: If lupus medications are causing mottled skin, you should consider working with a healthcare provider. They may recommend adjusting the dosage or switching to alternative medications. However, livedo reticularis is rarely dangerous. It is more of a cosmetic concern for most people.
  3. Blood thinners: If antiphospholipid antibodies cause the livedo reticularis, then the health care provider may prescribe a blood thinner, such as aspirin. If these antibodies are causing more significant problems (such as blood clots, strokes, and heart attacks), then stronger blood thinners such as warfarin may be prescribed
  4. Drugs that calm down the immune system. If lupus vasculitis causes the livedo reticularis, then your healthcare provider may prescribe drugs that calm down the immune system. For mild cases, hydroxychloroquine usually suffices. For more severe cases, the healthcare provider may prescribe immunosuppressants, such as steroids, methotrexate, belimumab [Benlysta], or anifrolumab [Saphnelo].

When to Seek Medical Attention

While mottled skin itself may not be a cause for immediate concern, it could be a sign of underlying vascular issues or complications. If mottled skin is accompanied by other symptoms, such as pain, numbness, or changes in skin texture, seeking prompt medical evaluation is crucial.

Individuals with lupus commonly associate lupus-mottled skin, or livedo reticularis, with a lacy pattern of reddish or bluish discoloration on the skin’s surface. It is important to understand that mottled skin may be a symptom of underlying vascular changes or medication-related side effects. While usually harmless, seeking medical attention and managing underlying conditions is essential for maintaining skin health and overall well-being. Working closely with healthcare providers can help individuals with lupus effectively manage mottled skin and other skin manifestations associated with this complex autoimmune disease.

For more in-depth information on livedo reticularis and other causes of mottled skin in lupus:

Read chapter 8 of The Lupus Encyclopedia, edition 2

Look up your symptoms, conditions, and medications in the Index of The Lupus Encyclopedia.

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What are your comments and opinions?

If you have mottled skin or livedo reticularis from lupus, what has your experience been? What do you recommend for other patients?

Do you have any questions to ask Dr. Thomas?

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Donald Thomas, MD edited and contributed to this post

9 Comments

  1. Thank you Dr. Thomas!
    I just ordered the new edition of The Lupus Encyclopedia.
    Thanks for all you do for the Lupus community!

  2. This is an article I needed to read four years ago. I discovered molted skin in a small area on the inside of my right knee, this was immediately after I had a stroke of unknown cause at age 44. I though maybe it was from hospital staff transferring me to the gurney after an MRI. I spent three years trying to figure out what the mottled skin was, which spread up and down both of my legs Ended up doing my own research and a follow up with Rhumatology to learn that it was Livedo R. Apparently I test negative for other autoimmune diagnosis except Lupus. Which is a relief at this point.

    • Christine: Thank you for sharing your story. Hopefully others will learn from it. Did your doctors end up calling it Sneddon syndrome? Sneddon syndrome is livedo along with stroke in the same patient.

      Donald Thomas MD

  3. Are SLE patients supposed to get the RSV vaccine?

    • We recommend RSV vaccine for all of our patients aged 60 and older as they are at higher risk for bad outcomes from RSV infection… Dr T

  4. Hi I’m Ashley from Austin TX I was recently diagnosed with Lupus SLE in September 2023, I just ordered your new book and was extremely curious about the skin reactions of Lupus . My main question is about the (molted skin or livedo reticularis) I have had this EXACT skin problems since 2017 it started small around my (rear end) then down the backside of my legs and now my entire body is covered in the lace like skin rash… and I’ve been to plenty of hospital visits since then but nobody told me anything about Lupus! My skin has the same reactions as described in your work… gets worse with extreme heat or cold, it can get (skin) very dry to were its painful, it gets bright red or small purple spots the whole definition my skin has been like this for years now AND I WAS HEALTHY! never got sick was in the gym twice a day always active I could work 10-14 hr days in retail and did independent contracting work (construction) but only recently this past September when I was hospitalized because (“all the sudden”) I got really sick did I find out about this (molted skin or livedo reticularis) was an ACTUAL symptom of this disease. Is it possible I had Lupus all this time and didn’t know? Is it possible that it can be in your body only to really affect you years later? Has this ever happened to anyone else? Is there a drug that will or can give me clear skin? is this normal? SOS

    • Ashley: If your rheumatologist confirms the findings as livedo, it could have been one of the first manifestations. SLE can start off with just one problem at a time and add things over time. The livedo markings are not uncomfortable in most people who have them, but the cosmetic changes can be quite troubling, of course. Unfortunately, we really do not have great treatments for livedo. I have seen it improve with warmth, but I cannot truly say that I’ve seen it go away with treatment of the lupus with immunosuppressants or blood thinners. That doesn’t mean to say it won’t (about anything is possible with lupus). I sure hope you do much better in the future.

      I hope you find my book useful. Make sure to do everything in chapter 44, The Lupus Secrets. If you like my book, I’d love to see a review on Amazon so you could share your experience with others.

      Donald Thomas, MD

  5. Is there a product I can put in my hair to help the extremely itchy dry scalp which I find myself scratching, even during my sleep, and my hair is thinning quickly. I know what alopecia is and suspect that is a problem for me, being just recently diagnosed via dermatology biopsy as having Lupus Erythromatosus and I have been taking Hydroxychloroquine for two years for RA so there seems to be nothing further that can be done to help me. I’m 73 years old and the itchy rash on my hands, arms, neck, shoulders, and face are very discouraging. I am using Vanicream shampoo, facial cleanser, moisturizer and body wash. I protect myself from sunlight with SPF 50. I just don’t know what to do about this itchy dry scalp!

    • Rayanne: So sorry to hear this. Many people do not realize how miserable pruritis (itchiness) can be. When it occurs at night, people cannot sleep and fatigue then worsens quality of life.

      If you were my patient, I’d want to know exactly what the cause of this problem is. Is it a drug reaction? Seborrheic dermatitis? Infection like tinea capitis? Xerotic dermatitis? etc. The treatment depends upon the cause.

      My plan would be to send you to my favorite medical dermatologist (someone who is very good with lupus and related disorders and not mainly into cosmetics etc). I rarely do not get a good answer using this approach. Then we can can come up with a successful plan.

      I hope this helps and I hope you get a good answer and treatment.

      Don Thomas, MD


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