Actinic Purpura


Article Author:
Wissem Hafsi


Article Editor:
Talel Badri


Editors In Chief:
Rhonda Coffman
Lindsay Iverson
Heather Templin


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/2/2019 12:20:47 AM

Introduction

Actinic purpura is a common disorder of dermal connective tissue due to damage from 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 that occur acutely after sun exposure.[1][2]

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.[3]

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.[4]

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 an 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.[5]

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 and involves protection from the sun via the application of sunscreen and wearing long-sleeved shirts. 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.[6][7]

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 with fair 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 can 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 option, and it is based on (1) physical clothing, (2) chemical means, via the regular application of sunscreen, and (3) behavioral by avoiding excessive sun exposure.

Enhancing Healthcare Team Outcomes

A multidisciplinary approach to actinic purpura

Actinic purpura is a very common condition, especially in elderly individuals. While the condition is benign, the skin is easily prone to bleeding, even with minor trauma. Healthcare workers including nurse practitioners can play a key role in the prevention of this condition. Patients should be encouraged to keep their skin moisturized, to use sunscreen, to wear sun-protective garments including a wide-brimmed hat, and to avoid direct sun exposure. It should also be noted that patients with actinic purpura are also more to actinic keratosis, hence awareness and a biopsy may be required.[6][8]

 


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Actinic Purpura - Questions

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Benign ecchymoses found on the backs of the hands and the extensor surfaces of the forearms are most likely which of the following?

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A 62-year-old female presented to the clinic appearing distressed. Upon assessment, she reveals that she has been a widow for 3 years. Recently, she was introduced to a man her age but worried because her arms and hands are becoming badly discolored. What type of medical skin condition is most likely?



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Actinic Purpura - References

References

Ceilley RI, Treatment of Actinic Purpura. The Journal of clinical and aesthetic dermatology. 2017 Jun     [PubMed]
Gerber PA,Buhren BA,Schrumpf H,Hevezi P,Bölke E,Sohn D,Jänicke RU,Belum VR,Robert C,Lacouture ME,Homey B, Mechanisms of skin aging induced by EGFR inhibitors. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2016 Oct     [PubMed]
Brouwer MW,Kemperman PM, [A woman with red-purple blotches]. Nederlands tijdschrift voor geneeskunde. 2013     [PubMed]
Luger A, [The skin in the elderly]. Zeitschrift fur Gerontologie. 1988 Sep-Oct     [PubMed]
Griffiths CE, The clinical identification and quantification of photodamage. The British journal of dermatology. 1992 Sep     [PubMed]
Lawrence N, New and emerging treatments for photoaging. Dermatologic clinics. 2000 Jan     [PubMed]
Demetriou C, Reversing precancerous actinic damage by mixing wavelengths (1064 nm, 532 nm). Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology. 2011 Jun     [PubMed]
Lipozenčić J,Bukvić Mokos Z, Dermatologic lasers in the treatment of aging skin. Acta dermatovenerologica Croatica : ADC. 2010     [PubMed]

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