Senile Purpura Case Study

Introduction

Actinic purpura or is a common disorder of dermal connective tissue due to the damage of chronic exposure to the sun. Initially described by Bateman in 1818, it is also known as Bateman senile purpura or Bateman disease. It usually affects elderly individuals, and it is characterized by dark purple blotches on the photo-exposed areas, especially the back of the hands and the extensor surfaces of the forearm. The term solar purpura has been used by some authors as a synonym to actinic purpura, but it is preferable to reserve it to purpuric lesions which occur acutely after sun exposure.

Etiology

Actinic purpura results from extravasation of the blood into the dermis after a minor trauma that is often neglected in the medical history. It is one of the signs of dermatoporosis, which indicates the skin fragility as well as skin atrophy and stellate pseudoscars.

Epidemiology

Actinic purpura is extremely common in elderly individuals, especially those with fair skin (skin types 1 and 2) who are more sensitive to sun exposure. Its prevalence increases with age. It is estimated to be present in about 12% of individuals after the age of 50 years and up to 30% after age 75. Actinic purpura occurs equally in both genders.

Pathophysiology

Actinic purpura results from extravasation of blood into the dermis. This phenomenon is due to the skin atrophy and the fragility of the blood vessels in elderly individuals, which is exacerbated by chronic sun exposure. Actinic purpura lesions are located on sun exposed areas, like the arms, face, and neck.

Skin atrophy in dermatoporosis is due to an alteration of collagen, similar to that which is seen in osteoporosis. This pronounced skin atrophy caused by the photo-aging makes the dermal vascular network very sensitive to the slightest trauma or shearing force.

The passage of red blood cells into the dermis results in the hemosiderin deposits in the interstitial space. There is no infiltration of the vessels and usually no inflammatory reaction of the dermal tissue. The absence of phagocytosis results in delayed resorption of extravasated blood. This fact results in the formation of purple patches and macules of ecchymotic aspect.

History and Physical

Actinic purpura presents as patches and macules with irregular edges, with sizes ranging from 1 cm to 4 cm in diameter on average. The lesions may appear dark purple and have extensive ecchymosis. The lesions often are present on the forearm and the back of the hands. However, they can affect other areas, such as the legs, neck, and face. The surrounding skin is generally of altered quality (thin, pigmented and inelastic), and there may be evidence of other photo-aging lesions such as lentigos and actinic keratoses. 

The purpuric lesions persist for about one to three weeks before resolving spontaneously. However, they do not undergo the phases of inflammation. It is possible that a residual deposit of hemosiderin in the dermis leaves a brown pigmentation. Actinic purpura, however, can continue to occur because of the already established cutaneous and vascular fragility. The ecchymotic lesions formed can cause a significant aesthetic problem and have a psychological impact; however, there is no risk of serious complications.

Evaluation

The diagnosis of actinic purpura is usually clinical and based on a good physical exam. In the rare cases where a biopsy is performed, the histological study will show a thinned epidermis ascending on an altered dermis with quantitatively reduced collagen fibers replaced by abnormal elastic fibers. The walls of the dermal vessels have a normal tensile structure, but there is extravasation of the red blood cells and hemosiderin deposits marked by Perls staining. In about 10% of cases, there is a neutrophilic infiltration that may lead to the misdiagnosis of actinic purpura as neutrophilic dermatosis or leukocytoclastic vasculitis.

Coagulation analysis is rarely necessary and usually, shows no abnormalities.

Treatment / Management

Actinic purpura is a benign condition that does not require specific treatment, particularly since other lesions continue to appear throughout life. The best treatment is preventive.; it is based on the intensive protection against sun exposure by wearing appropriate long-sleeved clothes. One should apply sunscreens with a high protection index (sun protection factor (SPF) greater than 50) daily to provide sufficient protection against the ultraviolet (UVB and UVA) rays. The sunscreen should be liberally applied to all sun-exposed areas regularly.

The therapeutic possibilities available for the actinic purpura lesions already formed are restricted. Tretinoin or retinoic acid (0.1%) is a derivative of vitamin A, which could theoretically reverse severe skin damage induced by ultraviolet light. Indeed, topical tretinoin is known for its role in the regeneration of dermal collagen and the reduction of the quality of abnormal elastin damaged by solar exposure. However, some authors demonstrate that the developed plaques of actinic purpura do not improve under local treatment with tretinoin. 

In 2002, actinic purpura was successfully treated in one patient with tissue engineered skin; however, no similar cases have been reported. 

More recently, it has been demonstrated that human epidermal growth factor may be a viable treatment of actinic purpura. It has been shown to increase the average skin thickness and reduce the number of purpuric lesions when applied twice daily for six weeks.

A citrus bioflavonoid blend has been tested for the treatment of actinic purpura. After six weeks, the treated group showed a 50% decrease in purpuric plaques with no reported side effects.

Laser therapy, which is widely used for the treatment of aging skin manifestations, is not indicated in actinic purpura. Moisturizing creams may be useful to treat frequently associated skin xerosis.

Pearls and Other Issues

Actinic purpura is a common, benign disease of elderly individuals who have clear skin types. The disorder appears to be caused by dermal and vascular fragility induced by chronic sun exposure. It does not predispose to serious complications, and the risk of bleeding is minimal. However, it could cause significant aesthetic and cosmetic damage and induce a significant psychological impact. Treatment is limited, mainly relying on creams based on vitamin A derivatives and moisturizing creams. Photoprotection remains the best treatment, and it is based on (1) physical clothing, (2) chemical means, by the regular application of sunscreens, and especially (3) behavioral by avoiding excessive sun exposure.

Questions

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References

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Lipozenčić J, Bukvić Mokos Z. Dermatologic lasers in the treatment of aging skin. Acta Dermatovenerol Croat. 2010;18(3):176-80. [PubMed: 20887699]

2.

Yoon TY, Kim HJ, Kim JW, Kim MK, Lee JY. Bowen's disease concealed by purpura. J. Dermatol. 2007 Jan;34(1):65-7. [PubMed: 17204105]

3.

Banta MN, Kirsner RS. Modulating diseased skin with tissue engineering: actinic purpura treated with Apligraf. Dermatol Surg. 2002 Dec;28(12):1103-6. [PubMed: 12472487]

4.

McKnight B, Seidel R, Moy R. Topical Human Epidermal Growth Factor in the Treatment of Senile Purpura and the Prevention of Dermatoporosis. J Drugs Dermatol. 2015 Oct;14(10):1147-50. [PubMed: 26461827]

5.

Wood BA, LeBoit PE. An 'inflammatory' variant of solar purpura: a simulant of leukocytoclastic vasculitis and neutrophilic dermatoses. Pathology. 2013 Aug;45(5):484-8. [PubMed: 23842046]

6.

Karadag AS, Parish LC, Lambert WC. Senile Purpura as a Stage of Dermatoporosis. Skinmed. 2017;15(2):91-92. [PubMed: 28528600]

7.

Berlin JM, Eisenberg DP, Berlin MB, Sarro RA, Leeman DR, Fein H. A randomized, placebo-controlled, double-blind study to evaluate the efficacy of a citrus bioflavanoid blend in the treatment of senile purpura. J Drugs Dermatol. 2011 Jul;10(7):718-22. [PubMed: 21720653]

8.

Rallis TM, Bakhtian S, Pershing LK, Krueger GG. Effects of 0.1% retinoic acid on Bateman's actinic purpura. Arch Dermatol. 1995 Apr;131(4):493-5. [PubMed: 7726601]

Figure

Actinic Purpura. Contributed by DermNetNZ

What is senile purpura?

Senile purpura is a common, benign condition characterised by recurrent formation of purple ecchymoses (bruises) on the extensor surfaces of forearms following minor trauma.

It is also known as Bateman purpura, after British dermatology pioneer Thomas Bateman, who first described it in 1818; and actinic purpura, because of its association with sun damage.

Senile purpura

Who is at risk of senile purpura?

Senile purpura affects over 10% of those aged over 50 years old. It is equally common in males and females.

Other risk factors include chronic sunlight exposure, and the use of oral or topical corticosteroids and anti-coagulants (blood thinners).

What are the clinical features of senile purpura?

Senile purpura is characterised by irregularly-shaped macules, 1 – 4 cm in diameter, that are dark purple in colour with well-defined margins. The lesions do not undergo the colour changes of a bruise and takes up to three weeks to resolve.

The surrounding skin is typically thin, inelastic and pigmented in association with others signs of skin ageing and sun damage.

The lesions are most commonly distributed on the extensor surface of forearms and dorsal aspect of hands. Infrequently, they also occur on necks and faces.

The patient may recall minor blunt trauma to skin preceding the appearance of the lesions. They may also note multiple similar lesions which have appeared in the past, but now resolved.

What causes senile purpura?

With age and photodamage, the dermal tissues become thin and increase the fragility of blood vessels. As a result, superficial vessels tear and rupture even with negligible trauma. The subsequent extravasation of blood into the surrounding dermis results in the development of dark purple ecchymoses.

Persistent brown pigmentation following the resolution of the bruises results from the deposition of haemosiderin, a component of red blood cells.

How is senile purpura diagnosed?

Senile purpura can be diagnosed based on clinical appearance alone.

Histologically, the epidermis is thinned and the dermis demonstrates significantly reduced amounts of collagen replaced by abnormal elastic fibres, as well as extravasated red blood cells. The vessel walls of the dermis are normal in structure.

Coagulation studies are rarely necessary and will typically be unremarkable.

What is the management of senile purpura?

Senile purpura is benign and self-resolving.

Patients should be educated on sun protection measures, including sunscreen application and sun-protective clothing to protect their skin from further photodamage.

What is the prognosis?

Although cosmetically displeasing, senile purpura is benign and unrelated to any systemic diseases or blood dyscrasias. It is however a risk factor for skin tears in institutionalised patients.

The purpuric lesions resolve over one to three weeks and may produce residual brown pigmentation of the skin. Unfortunately, senile purpura is recurrent in nature and associated with lifelong reappearance of new lesions.

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