The net-like, violaceous pattern on the infant’s skin was characteristic of livedo reticularis.
Livedo reticularis is thought to arise from a change in underlying cutaneous blood flow.1 The appearance of this condition reflects the configuration of underlying cutaneous vasculature. Arterioles oriented perpendicularly to the skin can surface from a network where blood flows from arteriole to capillary to venule. The reticular appearance is a result of increased visibility of the venous plexus.1
Common culprits of this manifestation are impaired arteriolar perfusion and venous congestion, which may be caused by vasospasm, arterial thrombosis, or hyperviscosity.1 If diagnostic biopsies are needed, they should be taken from the pale central areas.
Livedo reticularis can be categorized into groups to help delineate the patient-specific pathogenesis: idiopathic, primary, secondary (due to underlying disease; see below), and physiologic.1 Physiologic livedo reticularis, which this patient had, is known as cutis marmorata (CM); it occurs in response to cold temperatures. It may be more common, or visible, in individuals with lighter skin types and in preterm infants. The condition typically affects the lower extremities but may also occur on the trunk and upper extremities.1
Physiologic livedo reticularis usually resolves with warming of the extremities. Secondary livedo reticularis usually manifests in older patients and is due to serious conditions such as malignancies, antiphospholipid syndrome, and Sneddon syndrome. For these patients, coagulopathy and malignancy evaluation targeting the underlying cause of the livedo reticularis is warranted. Interestingly, livedo reticularis may also be associated with COVID-19, but this association has not been reported frequently in children.2
The infant in this case experienced rapid resolution with warming. The family was educated about the CM form of livedo reticularis and instructed to keep her warm. No other treatment or evaluation was indicated.
Photo courtesy of Daniel Stulberg, MD, FAAFP. Text courtesy of Christy Nwankwo, BA, University of Missouri-Kansas City School of Medicine and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.