By Pullen, Richard L Jr; Rowh, Mark E
The “Clinical Snapshot” series provides a concise examination of a clinical presentation including history, treatment, patient education, and nursing measures. Using the format here, you are invited to submit your “Clinical Snapshot” to Dermatology Nursing.
History: The patient is a 37-year-old female with a history of systemic lupus erythematosus (SLE). She is positive for antinuclear antibodies and anti-Ro/SSA antibodies. She also has antiphospholipid antibodies including anticardiolipin, anti-beta-2 glycoprotein I, and antiphosphatidylserine. She has a rash on her arms, which has a red mottled appearance. The rash is more prominent and takes on a purplish hue when she is exposed to cold temperatures. This rash does not cause pain nor discomfort.
Description: Livedo reticularis (LR) (see Figure 1) is a rash that results from dilation of capillary blood vessels. Stagnation of blood within these vessels causes mottled discoloration of the skin. It is described as being a reticular (net-like) reddish-blue discoloration of the skin. Anything that decreases blood flow further, such as exposure to cold, will make the condition worse.
Etiology: LR may be a benign condition or indicate systemic disease such as antiphospholipid antibody syndrome (APS), vasculitis, or arteriosclerosis. APS may occur as a primary disease or secondary to autoimmune disorders such as SLE.
Location: LR may be widespread or localized on the limbs or on the trunk or buttocks. Patients may also experience livedo on the palms of the hand.
Hallmark of the Disease: LR is a hallmark of cutaneous manifestation of APS. This syndrome is a disorder of the immune system that is characterized by excessive clotting of the blood. A diagnosis of APS is made when antiphospholipid antibodies are detected in the blood and the patient exhibits LR and/or has experienced a thrombotic event anywhere in the body.
Figure 1.
Reticular or net-like pattern of livedo. The rash fades somewhat when the skin is warmed.
Treatment: LR does not generally cause discomfort. No special treatment of the rash is indicated. The patient with APS may be treated with baby aspirin, clopidrogel bisulfate (Plavix), warfarin (Coumadin), or heparin to reduce the incidence of thrombosis.
Normal Course: LR may wax and wane during the course of APS. The rash may never completely disappear.
Patient Education: The patient should minimize exposure to cold environments to reduce the prominence of the rash. Monitoring antiphospholipid antibody levels is also important. The patient should report symptoms of a blood clot, such as changes in the color of an extremity, shortness of breath, and chest pain as well as any bleeding tendencies from anticoagulant therapy, to the health care provider.
References
Evans, J. (2004). Dermatoses are often the first sign of antiphospholipid antibody syndrome (APS). Internal Mediane News, 37(23), 19.
Pullen, R.L., Cannon, J.D., & Rushing, J.D. (2003). Managing organ-threatening systemic lupus erythematosus. MEDSURG Nursing, 72(6), 368-379.
Richard L. Pullen, Jr., EdD, RN, is a Professor of Nursing, Amarillo College, Amarillo, TX.
Mark E. Rowh, BS, RT(R), CNMT, is Director of Nuclear Mediane, Amarillo College, Amarillo, TX.
Copyright Anthony J. Jannetti, Inc. Feb 2006
Comments