Actinic purpura

Are You Confident of the Diagnosis?

Characteristic findings on physical examination

Actinic purpura, also known as Bateman’s or senile purpura, is due to the rupture of delicate blood vessel walls, leading to an erythematous purpura most often seen on the dorsum of the hands in elderly populations . Actinic purpura can also be seen on the upper extremities (Figure 1). Physical examination will reveal thin fragile skin, which has an increased tendency for bruising and tearing.

Actinic purpura seen on the forearm of an elderly female.

Expected results of diagnostic studies

Histopathology consists of features of aging skin including flattening of the dermal-epidermal junction, decreased elastic fibers, fibroblasts and collagen, as well as thinning of dermal vasculature.

Diagnosis confirmation

Differential diagnosis includes:

Palpable purpura (inflammation plus hemorrhage)

Noninflammatory retiform purpura (such as disseminated intravascular coagulation)

Inflammatory purpura- classic palpable purpura due to leukocytoclastic vasculitis

Ecchymosis differential diagnosis includes:

Steroid use (topical or systemic)

Vitamin C deficiency (scurvy)

Systemic amyloidosis

Ehler-Danlos syndrome

Who is at Risk for Developing this Disease?

Middle-aged persons and the elderly population are at risk. Actinic purpura is believed to be more common in men. Individuals with chronic sun exposure and/or long-term corticosteriod use (topical and systemic), are also more susceptible to actinic purpura. One study mentions zinc deficiency as a possible etiology for an increased risk in developing actinic purpura.

What is the Cause of this Disease?

Actinic purpura is caused by skin aging, both intrinsic and solar, and can occur with or without skin trauma.

Systemic Implications and Complications

This is a benign condition of aging and systemic implications and complications have not been reported.

Treatment Options

MEDICAL THERAPIES (the goal is to prevent further skin aging)

Topical retinoids

The theory is to thicken the dermis and improve the overall appearance of the skin. However, the risk of retinoid dermatitis may outweigh the benefits. Retin A 0.1% cream applied once at bedtime as tolerated; at least 3 months of treatment is needed to see any effect.

Topical vitamins C, E, K

Vitamins C and E are both antioxidants and are believed to offer some safeguard and reversal of photodamage; topical vitamin K is thought to offer some relief against bruising severity; however, more studies are needed to support these statements.

Alpha hydroxy acids (AHAs)

Herbal remedies such as arnica and bromelain- more studies are needed to fully assess the efficacy in reducing the severity of bruising when using these treatments.

Topical hormone therapy (ie, DHEA and progesterone creams)

Results are promising in using these treatments, however more studies are needed to fully examine the safety and benefits of these therapies.

SURGICAL THERAPIES

Apligraf

One case report describes this extreme procedure in which affected skin is excised first before placement of the graft. The increased risk in treating such a benign condition may be hard to justify, unless a significant problem exists such as recurrent wounds and infections.

OTHER MODALITIES

Other modalities, such as chemical peels, dermabrasion, laser resurfacing, nonablative laser resurfacing and fillers, are sometimes used to camouflage the veins and purpura of the dorsal hands. There are articles that suggest these treatment options; however, the risks do not outweigh the benefits in this benign disorder.

Optimal Therapeutic Approach for this Disease

Since actinic purpura is a benign condition and the lesions of actinic purpura can migrate, along with limited success with any one modality, treatment is not considered necessary but rather cosmetic.

Attempts to increase the dermal thickness have been tried with topical retinoids and AHAs with minimum benefits. Other topical agents such as vitamin C and K, have been tried with limited reported benefits. Procedures such as hyaluronic acid or calcium hydroxyapatite injections into the dorsal hands to camouflage purpura have been tried; bruising secondary to the injections may negate the potential benefits. Laser resurfacing as well as chemical peels and microdermabrasion have limited success.

Patient Management

-Minimize sun exposure

-Encourage consistent sunscreen use

-Moisturization of skin

-Healthy diet to insure adequate nutrition

-Minimize trauma (for example, shin guards may be useful in protecting the legs from developling ulcerative lesions)

Unusual Clinical Scenarios to Consider in Patient Management

None known.

What is the Evidence?

Banta, MN, Kirsner, RS. “Modulating diseased skin with tissue engineering: actinic purpura treated with apligraf”. Dermatol Surg. vol. 28. 2002. pp. 1103-6. (Case report of a 77-year-old white male who presented with actinic purpura, easy bruisability, and recurrent wounds on his left forearm. A thin-partial thickness section of his left forearm was removed and replaced with fenestrated Apligraf. He healed well post-peratively and did not experience new tears,brusing or trauma to the grafted location after 15 months.)

El-Alfy, M, Deloche, C, Azzi, L. “Skin responses to topical dehydroepiandrosterone: implications in antiageing treatment?”. Br J Dermatol. vol. 163. 2010. pp. 968-76. (Placebo-controlled, randomized, prospective study in 75 postmenopausal women who applied topical DHEA cream (ranging from 0.1-2%) twice daily to several areas on the body for 13 weeks. Results showed that this treatment has the potential to be an effective antiaging treatment in the future. Specific results include an increase in the expression of the androgen receptor, heat shock protein 37, and procollagen 1 and 3 mRNA in the dermis.)

Haboubi, NY, Haboubi, NA, Gyde, O. “Zinc deficiency in senile purpura”. J Clin Pathol. vol. 38. 1985. pp. 1189-91. (Forty total geriatric patients were divided into two groups (those with and without purpura), and were matched for age. Results showed that fasting plasma zinc levels were lower in those with senile purpura, than those without.)

Holzer, G, Riegler, E, Honigsmann, H. “Effects and side-effects of 2% progesterone cream on the skin of peri- and post menopausal women: results from a double-blind, vehicle-controlled, randomized study”. Br J Dermatol. vol. 153. 2005. pp. 626-34. (Results showed a significant increase in elasticity and firmness in the treatment group.)

Lawrence, N. ” New and emerging treatments for photoaging”. Dermatol Clin. vol. 18. 2000. pp. 99-112. (In-depth review of the histologic changes, clinical changes, and treatments (including vitamin C, vitamin D, hormones and alpha hydroxy acids as mentioned above ) for photoaging.)

Lewis, AB, Gendler, EC. ” Resurfacing with topical agents”. Semin Cutan Med Surg. vol. 15. 1996. pp. 139-44. (Reviews treatments for the aging skin; includes a discussion on vitamin C and topical hormone therapy.)

Seeley, BM, Denton, AB, Ahn, MS, Maas, CS. ” Effect of homeopathic arnica montana on brusing in face-lifts”. Arch Facial Plast Surg. vol. 8. 2006. pp. 54-9. (Double-blind study of 29 patients undergoing rhytidectomy that were treated perioperatively with arnica or placebo. In general, results showed that patients taking arnica had less ecchymosis than placebo.)

Shah, NS, Lazarus, MC, Bugdodel, R. “The effects of topical vitamin K on bruising after laser treatment”. J Am Acad Dermatol. vol. 47. 2002. pp. 241-4. (Double-blind, randomized, placebo controlled study of 22 patients divided into 2 groups; group 1 applied vitamin K cream to half of face and vehicle cream to other half twice daily for 2 weeks before PDL treatment; group 2 applied vitamin K cream to half of face and placebo cream to other half twice daily for 2 weeks after PDL treatment. Results showed that application of vitamin K before the laser treatment did not reduce brusing, however patients who applied vitamin K after the laser treatment did demonstrate a significant reduction in the severity of bruising.)

Wong, HY. ” Hypothesis: senile purpura is a prognostic feature in elderly patients”. Age Ageing. vol. 17. 1988. pp. 422-4. (Geriatric study of prognostic factors of senile purpura (SP) in 1125 elderly Chinese patients. Results showed an exponential increase of senile purpura with respect to age and a higher number of males suffering from SP than females.)

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