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; 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 mid-dermal blood vessels slows local blood flow in dilated superficial capillaries and small veins. Shock causes mottling from systemic vasoconstriction.
History and physical examination
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 better? Does anything make it worse? Does the patient have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?
Take the patient's vital signs. Observe the patient's skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check the capillary refill time. 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
Acrocyanosis.With acrocyanosis, 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 of acute arterial occlusion include skin 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, an 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 legs) 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 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.Cryoglobulinemia causes patchy livedo reticularis, petechiae, and ecchymoses. Other findings include fever, chills, urticaria, melena, skin ulcers, epistaxis, Raynaud's phenomenon, eye hemorrhages, hematuria, and gangrene.
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 a sudden onset of pallor, cool skin, restlessness, thirst, tachypnea, and slight tachycardia. As shock progresses, associated findings include cool, clammy skin; a 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.
Periarteritis nodosa.Skin findings in periarteritis nodosa 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.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, and aquagenic pruritus.
Systemic lupus erythematosus (SLE).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
Drugs.Vasoconstrictors administered at a high dose can cause mottling of the extremities.
Immobility.Prolonged immobility may cause bluish mottling, most noticeably in dependent extremities.
Thermal exposure.Prolonged thermal exposure, as from a heating pad or hot water bottle, may cause erythema ab igne—a localized, reticulated, brown-to-red mottling.
Nursing considerations
▪ Provide care to treat the patient's underlying condition.
▪ Monitor vital signs, especially noting blood pressure.
▪ Monitor the patient's skin for changes in the mottled appearance.
▪ Monitor pulses, noting the strength of impulse.
Patient teaching
▪ Teach the patient to avoid tight clothing and overexposure to cold or to heating devices, such as hot water bottles and heating pads.
▪ Discuss treatment of the underlying condition.
Pictures
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
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