Bubbles in the skin microcirculation underlying cutis marmorata in decompression sickness: Preliminary observations

The cutaneous form of decompression sickness (DCS) known as cutis marmorata is a frequent clinical presentation. Beyond a general acceptance that bubbles formed from dissolved inert gas are the primary vector of injury, there has been debate about pathophysiology. Hypotheses include: 1) local formation of bubbles in the skin or its blood vessels; 2) arterialisation of venous bubbles across a right to left shunt (RLS) with local amplification in bubble size after reaching supersaturated skin via the arterial circulation; and 3) passage of arterialised venous bubbles to the cerebral circulation with stimulation of a sympathetically mediated vasomotor response.

Four divers exhibiting cutis marmorata had the underlying tissue examined with ultrasound 4-5.5 hours after appearance of the rash. All subsequently underwent transthoracic echocardiography with bubble contrast to check for a RLS.

In all cases numerous small bubbles were seen moving within the skin microvasculature. No bubbles were seen in adjacent areas of normal skin. All four divers had a large RLS.

This is the first report of bubbles in skin affected by cutis marmorata after diving. The finding is most compatible with pathophysiological hypotheses one and two above. The use of ultrasound will facilitate further study of this form of DCS.