Skin, mottled
Skin, mottled: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Mottled skin is patchy discoloration indicating primary or secondary changes of the deep, middle, or superficial dermal blood vessels. It can result from a hematologic, immune, or connective tissue disorder; chronic occlusive arterial disease; dysproteinemia; immobility; exposure to heat or cold; or shock. Mottled skin can be a normal reaction, such as the diffuse mottling that occurs when exposure to cold causes venous stasis in cutaneous blood vessels (cutis marmorata).
Mottling that occurs with other signs and symptoms usually affects the extremities, typically indicating restricted blood flow. For example, livedo reticularis, a characteristic network pattern of reddish blue discoloration, occurs when vasospasm of the middermal blood vessels slows local blood flow in dilated superficial capillaries and small veins. Shock causes mottling from systemic vasoconstriction.
History
Mottled skin may indicate an emergency condition requiring rapid evaluation and intervention. (See Mottled skin: Knowing what to do.) However, if the patient isn’t in distress, obtain a history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything make it go away? Does the patient have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?
Physical assessment
Observe the patient’s skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check capillary refill. Also, palpate for the presence (or absence) of pulses and for their quality. Note breaks in the skin, muscle appearance, and hair distribution. Also, assess motor and sensory function.
Medical causes
Arterial occlusion (acute)
Initial signs of acute arterial occlusion include temperature and color changes. Pallor may change to blotchy cyanosis and livedo reticularis. Color and temperature demarcation develop at the level of obstruction. Other effects include sudden onset of pain in the extremity and possibly paresthesia, paresis, and a sensation of cold in the affected area. Examination reveals diminished or absent pulses, cool extremities, increased capillary refill time, pallor, and diminished reflexes.
Arteriosclerosis obliterans
Atherosclerotic buildup narrows intra-arterial lumina, resulting in reduced blood flow through the affected artery. Obstructed blood flow to the extremities (most commonly the lower) produces such peripheral signs and symptoms as leg pallor, cyanosis, blotchy erythema, and livedo reticularis. Related findings include intermittent claudication (most common symptom), diminished or absent pedal pulses, and leg coolness. Other symptoms include coldness and paresthesia.
Buerger’s disease
Buerger’s disease is a form of vasculitis that produces unilateral or asymmetrical color changes and mottling, particularly livedo networking in the lower extremities. It also typically causes intermittent claudication and erythema along extremity blood vessels. During exposure to cold, the feet are cold, cyanotic, and numb; later they’re hot, red, and tingling. Other findings include impaired peripheral pulses and peripheral neuropathy. Buerger’s disease is typically exacerbated by smoking.
Hypovolemic shock
Vasoconstriction from hypovolemic shock commonly produces skin mottling, initially in the knees and elbows. As shock worsens, mottling becomes generalized. Early signs include sudden onset of pallor, cool skin, restlessness, thirst, tachypnea, and slight tachycardia. As shock progresses, associated findings include cool, clammy skin; rapid, thready pulse; hypotension; narrowed pulse pressure; decreased urine output; subnormal temperature; confusion; and decreased level of consciousness.
Livedo reticularis (idiopathic or primary)
With livedo reticularis, symmetrical, diffuse mottling can involve the hands, feet, arms, legs, buttocks, and trunk. Initially, networking is intermittent and most pronounced on exposure to cold or stress; eventually, mottling persists even with warming.
Polycythemia vera
Polycythemia vera, a hematologic disorder, produces livedo reticularis, hemangiomas, purpura, rubor, ulcerative nodules, and scleroderma-like lesions. Other symptoms include headache, a vague feeling of fullness in the head, dizziness, vertigo, vision disturbances, dyspnea, and aquagenic pruritus.
Rheumatoid arthritis
Rheumatoid arthritis may cause skin mottling. Early nonspecific signs and symptoms progress to joint pain and stiffness with subcutaneous nodules, usually on the elbows. The patient may report morning stiffness.
Systemic lupus erythematosus
Systemic lupus erythematosus (SLE) is a connective tissue disorder that can cause livedo reticularis, most commonly on the outer arms. Other signs and symptoms include a butterfly rash, nondeforming joint pain and stiffness, photosensitivity, Raynaud’s phenomenon, patchy alopecia, seizures, fever, anorexia, weight loss, lymphadenopathy, and emotional lability.
Other causes
Immobility
Prolonged immobility may cause bluish mottling, most noticeably in dependent extremities.
Thermal exposure
Prolonged thermal exposure, such as from a heating pad or hot water bottle, may cause erythema Ab Igne — a localized, reticulated, brown-to-red mottling.
Special considerations
Mottled skin typically results from a chronic condition.
Pediatric pointers
A common cause of mottled skin in children is systemic vasoconstriction from shock. Other causes are the same as those for adults.
Geriatric pointers
In elderly patients, decreased tissue perfusion can easily cause mottled skin. Besides arterial occlusion and polycythemia vera, conditions that commonly affect patients in this age-group, bowel ischemia is common in elderly patients who present with livedo reticularis, especially if they also have abdominal pain or bloody stools.
Patient counseling
Teach patients to avoid tight clothing and overexposure to cold or to heating devices, such as hot water bottles and heating pads. If the patient has a chronic condition, such as SLE or periarteritis nodosa, advise him to watch for mottled skin because it may indicate a flare-up of his disorder.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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