Skin, mottled
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. Other causes include 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.
Act Now: Mottled skin may indicate an emergency condition requiring rapid evaluation and intervention. If the patient is pale, cool, clammy, and mottled at the elbows and knees or all over, he may be developing hypovolemic shock. Monitor his vital signs, and note tachycardia or a weak, thready pulse. Observe the neck for flattened jugular veins, and assess the patient for anxiety. If you detect these signs and symptoms, place the patient in a supine position in bed with his legs elevated 20 to 30 degrees. Administer oxygen by nasal cannula or face mask and begin cardiac monitoring. Insert a large-bore I.V. line for rapid fluid infusion or blood product administration and prepare to insert a central line or pulmonary artery catheter. Also prepare to insert a catheter to monitor urinary output.
Localized mottling in a pale, cool extremity that the patient describes as painful, numb, and tingling may signal acute arterial occlusion. If the patient presents with these signs and symptoms, immediately check his distal pulses. If they’re absent or diminished, you’ll need to insert an I.V. line in an unaffected extremity and prepare the patient for arteriography or immediate surgery.
Assessment
History
If the patient isn’t in distress, obtain his medical history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything relieve it? Does he have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?
Physical examination
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. Assess motor and sensory function.
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. Arterial occlusion and polycythemia vera, which are common in this age-group, may also cause mottled skin. Suspect bowel ischemia in elderly patients who present with livedo reticularis, especially if they also report abdominal pain or bloody stools.
Medical causes
Acrocyanosis
. With acrocyanosis, a rare disorder, anxiety or exposure to cold can cause vasospasm in small cutaneous arterioles. This results in persistent symmetrical blue and red mottling of the affected hands, feet, and nose.
Arterial occlusion (acute)
Initial signs include temperature and color changes. Pallor may change to blotchy cyanosis and livedo reticularis. Color and temperature demarcation develop at the level of the obstruction. Other effects include a 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
A form of vasculitis, Buerger’s disease 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.
Cryoglobulinemia
A necrotizing disorder, cryoglobulinemia causes patchy livedo reticularis, petechiae, and ecchymoses. Other findings include fever, chills, urticaria, melena, skin ulcers, epistaxis, Raynaud’s phenomenon, eye hemorrhage, hematuria, and gangrene.
Hypovolemic shock
Vasoconstriction from shock commonly produces skin mottling, initially in the knees and elbows. As shock worsens, mottling becomes generalized. Early signs include a sudden onset of pallor, cool skin, restlessness, thirst, tachypnea, and slight tachycardia. As shock progresses, associated findings include cool, clammy skin as well as a rapid, thready pulse accompanied by hypotension, narrowed pulse pressure, decreased urine output, subnormal temperature, confusion, and a decreased level of consciousness.
Livedo reticularis (idiopathic or primary)
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.
Periarteritis nodosa
Skin findings include asymmetrical, patchy livedo reticularis, palpable nodules along the path of medium-sized arteries, erythema, purpura, muscle wasting, ulcers, gangrene, peripheral neuropathy, fever, weight loss, and malaise.
Polycythemia vera
A hematologic disorder, polycythemia vera 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, aquagenic pruritus, and night sweats.
Rheumatoid arthritis (RA)
RA may cause skin mottling. Early nonspecific signs and symptoms progress to joint pain and stiffness with subcutaneous nodules, usually on the elbows.
Systemic lupus erythematosus (SLE)
A connective tissue disorder, SLE 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.
Nursing considerations
Assess for exacerbation of the underlying condition, and refer the patient for medical treatment. Maximize circulation to the affected areas by keeping them warm and in proper alignment.
Patient teaching
If the patient has a chronic condition, such as SLE, periarteritis nodosa, or cryoglobulinemia, advise him to watch for mottled skin because it may indicate a flare-up of his disorder. Encourage the patient to avoid wearing tight clothing and to avoid overexposure to cooling or heating devices.
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Hemorrhagic rash
Read excerpts from these other book chapters related to Hemorrhagic rash:
Medical Books Excerpts
- Purpura
- "In a Page: Signs and Symptoms" (2004)
- [ read ]
- Purpura
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Purpura
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Purpura
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Skin, mottled
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Skin, mottled
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Purpura
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Purpura
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
More About Causes of Hemorrhagic rash
» Next page: Purpura (Signs & Symptoms: A 2-in-1 Reference for Nurses)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
