Bier spots, also known as Marshall-White syndrome, are ischemic pale macules caused by vasospasm in the skin and are characterized by marble-like spots on the forearms and hands when the brachial artery is tightened with a sphygmomanometer cuff.


The causes of the disease are currently unknown, and may be cutaneous capillary dysfunction and vasospasm, resulting in ischemic pale spots. It has also been reported that varices or increased venous obstruction may be the cause. The disease mostly occurs in middle-aged males with neuroticism, and may be accompanied by insomnia and tachycardia. It is also thought that red spots are caused by vasodilatation, while pale spots are caused by vasoconstriction.

Signs and Symptoms

The disease occurs mostly in the distal extremities, palms, and dorsal feet, as well as trunk. The clinical manifestations are pisolitic, 1 - 2cm in diameter, rounded or subrounded, sharply demarcated or poorly demarcated, light pale spots, or pale spots on the dark red or light red spots. The pale spots are with skin temperature lower than that of the peripheral pink skin, and this situation is more obvious when patients drop their hands for a while. In addition, the skin lesions of the extremities, hands, and feet are obvious when patients drop their limbs, while the skin lesions are subtle or reduced when the affected limb is raised.

Figure 1 Bier spots on the palm

Figure 2 Bier spots on the hand

Figure 3 Bier spots on the leg

Figure 4 Bier spots on the leg


The disease can be diagnosed on the basis of clinical manifestations.


There is currently no effective treatment for this disease, and treatment is generally not required, but oral vasodilators, such as nifedipine, can be tried.