VASCULAR LESIONS.

Livedo reticularis, secondary to spasm of the dermal ascending arterioles, is often seen on the forearms, legs, and even the torso. Occlusion may result in ulcers. A strong association is seen with Raynaud's phenomenon and with antiphospholipid antibodies. Telangiectases are found commonly on the face and elsewhere. They represent dilated blood vessels and not an active inflammatory lesion. Telangiectases appear more prominent when the patient blushes, is in a hot environment (shower), or takes a vasodilator (e.g., alcohol, calcium channel blocker). Telangiectases may also be associated with solar damage, aging, hypertension, diabetes, and other rheumatic diseases.

Raynaud's phenomenon occurs in 17 to 30% of patients. It is characterized by blanching of the nail beds, fingers, toes, and occasionally the ears, nose, and tongue. The vasospasm of small to medium-sized arteries may be induced by cold, cigarette smoke, caffeine, decongestants, stress, and other factors. After ischemia, there may be bluing and graying followed by vasodilation with warming and reddening. Gangrene is rare.

Vasculitis of post-capillary venules with neutrophil or lymphocyte accumulation develops in 20% of patients and is manifested as urticaria or purpura. When small arteries are affected, microinfarcts of the fingertips, toes, nail cuticles, forearms, or ankles may develop; the lesions about the ankle may ulcerate. The blood vessels typically have fibrinoid necrosis, thrombosis, and a variable cellular infiltrate. Patients with vasculitis have low serum complement and high serum immune complex levels and may have antiphospholipid antibodies.

Other less common vascular lesions include Janeway's spots on the palms, Osler's nodes on the fingertips, atrophie blanche lesions, and chilblain lupus (pernio) on the fingers and toes.