APPROACH TO PURPURA

By Dr.Kamran M Saeed

PGR Medicine DHQ Rwp

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Terms• Petechiae

– Pinpoin-sized (<3mm) macule of blood in the skin

• Purpura– Larger macule/papule (>3mm) of blood in

the skin• Echymosis

– Large confluent area of Purpua

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CAUSES• Primary cutaneous pathology• Systemic disease

• Palpable• Non-palpable

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Primary cutaneous disorders

• Trauma• Solar purpura• Steroid purpura• Capillaritis• Livedoid vasculopathy

NON PALPABLE

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Systemic diseases

• Clotting disturbances   – Thrombocytopenia (including ITP)– Abnormal platelet function– Clotting factor defects

• Vascular fragility–  Amyloidosis–  Ehlers-Danlos syndrome–  Scurvy

NON PALPABLE

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Systemic diseases•  Thrombi

– DIC–  Monoclonal cryoglobulinemia–  HIT & thrombosis –  TTP & HUS–  Warfarin reaction

•  Emboli– Cholesterol– Fat

• Possible immune complex– Gardner-Diamond syndrome (autoerythrocyte sensitivity)– Waldenström's hypergammaglobulinemic purpura

NON PALPABLE

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Systemic diseases• Vasculitis  

– Cutaneous small-vessel vasculitis   – Polyarteritis nodosa   

• Emboli  – Acute meningococcemia   – Disseminated gonococcal infection   – Rocky Mountain spotted fever   – Ecthyma gangrenosum

P

A

L

P

A

B

L

E

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PRIMARY CUTANEOUS DISORDERS

(non-palpable)

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Solar Purpura

• Caused by chronic sun exposure• Usually on forearms, extensor surface

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Steroid purpura

• 2ndry to:– potent topical glucocorticoids – Endogenous/exogenous Cushing's syn.

• On any location

Steroid & Solar purpura, both are caused by alteration of the supporting connective tissue that surrounds the dermal blood vessels

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Capillaritis

• Pigmented purpuric dermatosis• Perivascular lymphocytic inflammation• Bright red petechiae, 1–2 mm size,

scattered w/in annular or coin-shaped yellow-brown macules

• Mainly in lower part of legs

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SYSTEMIC DISEASES(non-palpable purpura)

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Clotting disturbances

• Thrombocyotopenia & abnormal plt function, clotting factor defects:

– Usually starts in lower extremities, may later involve whole body

– Also includes purpura 2ndry to VHF

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Vascular fragility

• Congenital, acquired & herititary– Ehlers-danlos syn– Scurvy– Systemic amyloidosis

• Fragile blood vessels especially capillaries d/t poor/lax supporting tissue

•prominent in the lower extremities•perifollicular in distribution, with flattened corkscrew hairs

• Generalized.• Associated features,

like joint hypermobility, lax skin, hernias, MVP, AA

•can occur at any site•Periorbital hemorrhage

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Thrombi

• DIC:– Triggered by

1. Infection

2. Injury

3. Neoplasms

– Generalized– Purpura fulminans

•A form of DIC associated w/ fever & hypotension•Occurs more in children•Following an infection such as varicella, scarlet fever, or URTI

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Thrombi

• Monoclonal cryoglobulinemia:– Associated with:

1. MM

2. Waldenström's macroglobulinemia

3. Lymphocytic leukemia

4. Lymphoma

– Primarily lower extremities– hemorrhagic infarcts (fingers & toes)– Exacerbation following cold exposure

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Thrombi

• TTP & HUS– Hemorrhagic infarcts– Generalized thrombocytopenic purpura– Fever– Microangiopathic hemolytic anemia– Renal failure

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Thrombi

• Warfarin:– warfarin-induced necrosis– develops between 3rd & 10th Day of

treatment• Heparin:

– HIT

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Emboli

• Cholesterol emboli:– Usually in lower extremities– Atherosclerosis– Anticoagulation– Vascular procedures– Livedo reticularis

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Emboli

• Fat embolism:– Post trauma– Upper body distribution

• Other emboli:– Atrial myxomas– Infective endocarditis

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Possible immune complex

• Gardner-Diamond syndrome:– Females– Ecchymoses w/in areas of painful, warm

erythema– ?Psychogenic purpura?

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Possible immune complex

• Waldenström's hypergammaglobulinemia– Chronic disorder – Petechiae on lower extremities– IgG–anti-IgG molecules– Ppt by prolonged standing or walking

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SYSTEMIC DISEASES(palpable purpura)

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Vasculitic

• Cutaneous small-vessel vasculitis:– Leukocyotoclastic vasculitis (LCV)– Inflammatory damage to cutaneous

vessels– Causes:

1. Drugs

2. Infections

3. CTD/autoimmune (HSP)

• PAN:

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Emboli

• G –ve cocci (meningococcus, gonococcus)

• G –ve (Enterobacteriaceae)• G +ve cocci (Staphylococcus)• Rickettsia• Candida & opportunistic fungi

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Emboli

• Acute meningococcemia:– primarily on trunk, lower extremities,

pressure sites– 1mm to several cm– gunmetal-gray color w/in the lesions– Associated findings

• Preceding URTI• Fever• Meningitis• DIC

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Emboli

• Disseminated gonococcal infection:– Papules & vesicopustules w/ central

purpura or hemorrhagic necrosis– Distal extremities– Associated features

1. Arthralgias

2. Tenosynovitis

3. Fever

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Emboli

• Rocky Mountain spotted fever:– fever, chills, severe headache, and

photophobia precede onset of cutaneous eruption

– erythematous macules & papules on wrists, ankles, palms, & soles

– Spread centripetally

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Emboli

• Ecthyma gangrenosum:– edematous, erythematous papules or

plaques and then develop central purpura and necrosis

– Associated w/ G –ve infections

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PURPURA

Non-palpable

Primary Skin pathologies

SystemicClotting problems

Vessel fragilityThrombiEmboliimmune

Palpable

VasculitisEmboli

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THE END

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