Overview of Purpura
A benign dermatologic connective tissue disorder commonly seen in the elderly that manifests itself primarily as purpura, a brownish-red or purple rash or plaques on exposed areas of the skin, which recurs due to degenerative skin changes and increased skin fragility associated with long-term sun exposure in the elderly.
Definition
Age-related purpura is a common benign connective tissue disease of the dermis, mainly due to long-term sun exposure of exposed skin and aging skin thinning, laxity, lack of elasticity, resulting in the loss of support of connective tissue around small blood vessels, and traumatic rupture of blood vessels in the skin caused by bleeding.
The disease was first described by Bateman in 1818, so it is also known as Bateman (Bateman) purpura, or Bateman’s disease, but also known as photodamaged purpura, solar purpura, senile scurvy, senile artificial purpura.
It manifests as brownish-red or purple macules or patches with clear borders and irregular contours on the backs of the hands, neck, face and extensor sides of the forearms and other exposed parts of the skin in the elderly. It is not accompanied by other symptoms such as itching or pain. The skin texture of the skin surrounding the purpura usually changes, such as thinning, discoloration, and lack of elasticity.
Morbidity
Age-related purpura occurs in people over 65 years of age, especially those with fair skin who are more sensitive to sun exposure. It can occur naturally or after minor trauma [1-2].
Its prevalence increases with age and years of exposure to ultraviolet light. It is estimated that about 12% of the population will develop the disease after the age of 50 years; after the age of 75 years, the percentage can be as high as 30%, which means that 30 out of 100 people over the age of 75 years will develop the disease.
Age-related purpura usually affects men and women equally.
Causes
Causes
Age-related degenerative changes
In the elderly, collagen, elastin, fat and other tissues in the subcutaneous connective tissue atrophy and relax, resulting in increased skin fragility due to the degeneration of the connective tissue around the vascular beds, leading to loss of vascular support. This is the most fundamental reason for the occurrence of senile purpura.
In addition, the phagocytosis function of phagocytes in the tissues of the elderly is weakened, resulting in delayed blood absorption, causing ferric hemoflavin deposition at the extravasation of erythrocytes.
Long-term sunlight exposure
Prolonged sunlight exposure, especially ultraviolet rays in sunlight, can lead to thinning and sagging of the skin, atrophy of subcutaneous fat, loss of support and lack of elasticity around small blood vessels [3-5].
Predisposing factors
Trauma is the main cause of senile purpura, mild trauma or skin movement can pull small blood vessels, resulting in rupture of blood vessels and extravasation of erythrocytes, which can lead to subcutaneous hemorrhage and petechiae.
Symptoms
Main Symptoms
Purpuric skin lesions may resolve on their own, usually within 1 to 3 weeks, and may retain brown pigmentation after resolving on their own. However, because increased skin and vascular fragility has occurred, senile purpura may continue to occur, and the condition often recurs.
Other symptoms
In addition to the typical manifestations of senile purpura described above, the skin surrounding the purpura is often thin and atrophic, dry and inelastic, with sparse hair.
There are also manifestations of photoaging skin damage such as wrinkles, freckles, grayish skin tone, and the appearance of actinic keratosis and stellate pseudo-scarring [1-3].
Medical Treatment
Department of Medicine
Dermatology
Patients with skin purpura and ecchymosis on the exposed areas of the face, neck and limbs are advised to consult a dermatologist promptly.
Hematology
If skin purpura is combined with recurrent nosebleeds, gum bleeds, vomiting of blood and black stools, or bleeding from wounds that do not coagulate easily, it is recommended to consult the hematology department.
Preparation for medical treatment
Preparation for consultation: registration, preparation of information, common problems
Tips for Medical Consultation
The doctor will need to observe the skin or take a biopsy, so it is recommended to wear clothes that are easy to put on and take off.
You can take photos of past rashes with your cell phone to give the doctor more reference.
If you have previous experience, bring along relevant medical records, examination reports and laboratory tests.
Preparation Checklist for Doctor’s Visit
Symptom list
Especially focus on the time of symptom onset, special manifestations, etc.
Are there any triggers for the appearance of skin lesions? Was there any trauma or prolonged exposure to sunlight before the onset of the rash? Where does the rash appear?
Are the skin lesions itchy? Does it hurt?
Is there any discomfort such as nosebleeds or bleeding gums?
Are there factors associated with exacerbation or reduction of symptoms?
Are there enlarged lymph nodes?
Medical History Checklist
Have there been similar symptoms before? If so, how many times have they occurred? What caused them?
Have you received any treatment? What medications were used? How effective was the treatment?
Are you usually a picky eater? Do you have a vitamin C deficiency?
Is there anyone in the family who has suffered from a similar disease?
Are there any other diseases such as hypertension, cerebrovascular disease, etc.?
Is there a history of drug allergy, blood transfusion?
Is there a history of long-term use of hormones and anticoagulants?
Are there any hematologic disorders such as platelet lowering, coagulation disorders, hematologic tumors, etc.?
Checklist
Test results in the past six months, which can be brought to the doctor’s office
Hematology test results: including blood routine, coagulation function, biochemistry routine, etc.
Urine routine, fecal routine, fecal occult blood results, etc.
Pathology test results.
Ultrasonography or other imaging test results.
Medication list
Medication use in the last 3 months, if available, bring the box or package to the doctor’s office
What medications have been used? Such as steroid hormones and anticoagulants?
Any related medications used to relieve symptoms?
Diagnosis
Diagnosis is based on
Combined with the patient’s age of onset, typical skin manifestations and relevant medical history, a preliminary clinical diagnosis can be made. Complete blood routine, coagulation function are normal, if necessary, complete the skin histopathological examination to confirm the diagnosis.
Medical history
Relevant medical history can assist the doctor’s diagnosis, for example:
Middle-aged and old age onset.
Purpura occurs in areas prone to trauma or exposure.
Recurrent episodes that may subside on their own.
Clinical manifestations
Skin purpura: recurrent episodes, mostly on the back of hands, neck, face and forearm extensors and other exposed areas, brownish-red or purple rash, patches, pressure does not fade.
Photodamaged skin: often combined with wrinkles, freckles, grayish yellow skin tone and signs of photodamaged skin such as actinic keratosis and stellate pseudo-scarring.
Laboratory Tests
Age-related purpura usually does not have positive laboratory test results, but it is still necessary to refine the tests to rule out other diseases and make a differential diagnosis.
Hematologic tests
Blood routine: to detect whether the patient’s white blood cells, platelets, red blood cells, etc. are normal.
Coagulation index: to determine whether the patient’s coagulation function is abnormal.
Biochemical routine: to detect whether the patient’s liver and kidney functions are damaged.
Calcitoninogen, blood sedimentation, C-reactive protein: to determine whether the patient has inflammation and infection.
Urine routine
To determine whether the patient has hematuria, urinary protein and urinary tract infection, etc., and to clarify whether there is kidney involvement.
Imaging
Aging purpura usually does not have positive imaging findings, improve the relevant examination can identify other diseases. Commonly used examinations include ultrasound, chest X-ray, CT and so on.
Improvement of ultrasound of the skin damage area can determine the presence of thrombus and hematoma to assist in the diagnosis.
Chest X-ray and brain CT can be perfected as appropriate according to the condition. If accompanied by fever, cough, shortness of breath and sputum, chest X-ray or chest CT can be perfected to determine whether there is pneumonia.
Pathologic examination
Pathologic examination is usually not necessary, but patients with senile purpura are prone to actinic keratosis, so timely detection and biopsy may be necessary. Especially in combination with other diseases, it is difficult to make a definitive diagnosis and it may be necessary to refine the skin tissue biopsy to confirm the diagnosis.
Histopathologic examination reveals an atrophic thinning of the epidermal dermis, degeneration of elastic fibers, lax collagen arrangement, ruptured and thinned small veins with a large number of disorganized abnormal keratin-forming cells, and there may be a marked decrease in collagen content. The dermis exhibits erythrocyte spillage, and in later stages, iron-containing hemosiderin deposits are seen, which can be labeled by Prussian blue staining.
Neutrophilic infiltration is present in some cases, so it may be misdiagnosed as neutrophilic dermatosis or leukocytoclastic vasculitis.
Other tests
Capillary fragility test: By applying localized pressure to the arm to block venous blood flow, the number of bleeding dots appearing on the skin within a certain range is examined, mainly used to assess the permeability and fragility of the capillary wall. Capillary fragility test is mostly positive in patients with senile purpura [1,6-10].
Differential diagnosis
Purpura simplex
It also presents as recurrent purpura of the skin without other abnormalities.
It is most common in young women, may be associated with the menstrual cycle, and occurs in both lower extremities.
Scurvy
Also known as vitamin C deficiency, it is a chronic deficiency of vitamin C due to reduced food intake or impaired absorption, causing bleeding in many parts of the body, such as gums, skin, joints, internal organs, etc., pallor, fatigue, and skeletal symptoms.
It can be seen in infants, young children or the elderly. Measurement of fasting serum vitamin C concentration is reduced, and treatment with massive vitamin C supplementation is effective.
Hemophilia
This disease is an X-chromosome inherited bleeding disorder, the vast majority of patients are male, female patients are rare.
It is characterized by delayed, persistent and slow bleeding, and the most common bleeding sites are skin and muscle bleeding, followed by bleeding in joint cavities.
It runs in families and can be diagnosed by coagulation factor VIII activity (FVIII:C) assay supplemented by FVIII antigen assay and coagulation factor IX activity (FIX :C) assay supplemented by FIX antigen assay.
Treatment
Aims of treatment: Benign lesions usually subside on their own without treatment. However, they are prone to recurrence, affecting the appearance and causing emotional distress, so prevention of recurrence is the key.
Treatment principle: Preventive treatment is the mainstay. Most of the treatments have limited effect on the already formed senile purpura.
Preventive treatment
Sun protection: Avoid sun exposure during peak sunlight hours, seek shade to avoid the sun, apply sunscreen and wear long-sleeved shirts to prevent excessive sun exposure. Widely apply sunscreen with a high protection index, such as sun protection factor (SPF) > 50, to exposed areas and reapply on a regular basis.
Avoid trauma and bumps: Be gentle in your daily actions and pay attention to skin protection. Keep the bedsheets flat, bedding and clothing soft and comfortable.
Medication
Vitamin A derivatives
Retinoic acid or retinoic acid (0.1%) is a derivative of vitamin A. It is theorized that this derivative can reverse severe skin damage induced by UV light. However, studies have shown limited efficacy in established senile purpura.
It needs to be used under medical supervision, preferably at night.
Vitamin C
Vitamin C increases capillary densification and decreases permeability. It has a certain effect on the improvement of skin elasticity and thickness.
Vitamin E
Vitamin E has the effect of delaying skin aging.
Niacin Tablets
Niacin tablets can delay skin roughness and aging.
Rutin
Rutin can maintain the elasticity of blood vessels, increase the resistance of capillaries and reduce bleeding. Commonly used drugs include compound rutin tablets.
Mucopolysaccharide polysulfate
Mucopolysaccharides polysulfate can promote the purpura to subside and reduce hyperpigmentation [1-2,10].
Questions you may be concerned about
How to treat age-related purpura
Age-related purpura is treated with medication and lifestyle modifications.
Age-related purpura is purpura that occurs in the skin and subcutaneous tissues, and is related to factors such as loose subcutaneous tissues and long-term exposure to sunlight in the elderly. It can subside on its own and often recurs. Commonly used drugs are vitamin C, vitamin E, anabolic hormone. Glucocorticoids should be used with caution.
Commonly used drugs include vitamin C, vitamin E, anabolic hormone, vitamin A acid preparations. Use glucocorticoids with caution to avoid aggravating the condition. If you have high blood pressure, diabetes, etc., you should actively treat the underlying disease and control your blood pressure and blood sugar within the normal range.
To strengthen the care, protect the skin, avoid trauma, sun exposure, etc., to do a reasonable diet, to ensure balanced nutrition.
However, it is important to note that medication must be used under the guidance of a doctor, not self-medication.
Prognosis
Cure
Although age-related purpura is recurrent, the prognosis is good. Generally, the skin damage tends to subside on its own within 1~3 weeks, which may leave hyperpigmentation and sometimes scarring, and mostly does not cause other complications.
Daily
Daily Management
Dietary management
Take care to have a balanced diet, eat more fresh vegetables and fruits, and supplement multivitamins.
Supplement with high quality protein, such as eggs and lean meat.
Life Management
Pay attention to the protection of skin and mucous membranes in daily life, and do not use skin care products of unknown composition on your own.
Keep the skin clean, the water temperature should not be too high when bathing, avoid contact with alcohol, etc..
Establish a reasonable daily routine, ensure sufficient sleep and avoid overwork.
Exercise in moderation to improve immunity.
Avoid bumps and trauma in daily life.
Avoid sun exposure during peak sunlight hours, apply sunscreen and wear long-sleeved shirts for protection.
Psychological support
This is a benign disease with no bleeding tendency and can improve on its own. It may leave pigmentation, such as breakouts, and sometimes scarring after healing.
There is no need for excessive anxiety. If you are troubled by this, ask your attending physician about the efficacy and adverse effects of various treatment options and learn about skin care.
Communicate fully with your family or friends, express your emotions, and set positive life goals.
Disease monitoring
Observe the skin lesions. If brownish-red or purple rash reappears on exposed areas of the skin, it may indicate a recurrence of purpura, so consult the attending physician for follow-up.
Prevention
Participate in physical exercise in moderation, ensure sufficient sleep, and improve immunity.
Adopt good personal habits, pay attention to skin care, use moisturizing milk or skin barrier repair milk.
Pay attention to a balanced diet, eat more fresh vegetables and fruits, and supplement multivitamins, such as vitamin C.
Avoid sun damage: Avoid sun exposure during peak sunlight hours, apply sunscreen and wear long-sleeved shirts for protection.
Avoid trauma and bumps: Be gentle in your daily actions, pay attention to skin care, keep bed sheets flat, bedding and clothing soft and comfortable.