Purpura simplex (inflammatory purpura without vasculitis): a clinicopathologic study of 174 cases

Therapeutic Approach in Pigmented Purpuric Dermatoses-A Scoping Review

Pigmented purpuric dermatoses (PPD) encompass a group of chronic skin conditions characterized by the presence of petechiae, purpura, and pigmentation changes. While generally benign, these dermatoses can be persistent and aesthetically bothersome. Key clinical features include red to brownish patches with a distinctive "cayenne pepper" appearance, predominantly localized on the lower extremities, particularly the shins. Subtypes include Schamberg disease, Majocchi's disease, Gougerot-Blum disease, Ducas and Kapetanakis pigmented purpura, and lichen aureus. Diagnosis relies primarily on clinical evaluation of skin lesions, with biopsy as a confirmatory tool. Although the exact cause of PPD remains unclear, capillary fragility and red blood cell extravasation are implicated. Treatment strategies for PPD aim to alleviate symptoms, considering the generally benign and chronic nature of the condition. As there is no standardized treatment, various methods with varying efficacy are employed. After searching SCOPUS and PubMed databases, we assessed 42 original articles to present current knowledge regarding therapy of PPD. This review will compare treatment approaches specifically in Schamberg disease and other manifestations of pigmented purpuric dermatoses.

Chronic venous disease, platelet and haemostatic abnormalities contribute to the pathogenesis of pigmented purpuric dermatoses

Background

To investigate the aetiology of pigmented purpuric dermatoses (PPD).

Methods

63 patients with a provisional diagnosis of PPD were assessed. Skin biopsies were performed to confirm the clinical diagnosis. Haemostasis was assessed using platelet function analyser-100 (PFA-100), light transmission aggregometry (LTA), impedance aggregometry (Multiplate) and measurement of clotting times and clotting factors. Chronic venous disease (CVD) was assessed by duplex ultrasound. When not contraindicated, patients were advised to discontinue haemostatic-modifying drugs or supplements for 4 weeks after which the laboratory measurements were repeated and the clinical resolution of PPD was assessed. Subsequently, a cohort of patients identified with CVD underwent endovenous interventions and further resolution of PPD was assessed.

Results

CVD was found in 48 patients (76.2%) while haemostatic abnormalities were found in 36 (57.1%). 30 patients (47.6%) had concurrent CVD and haemostatic abnormalities. Modifiable risk factors such as the intake of platelet inhibitors or other drugs and supplements such as fish oil were identified in 53 patients (84.1%). These could be ceased in 35 patients of whom 28 (80.0%) achieved either complete or partial resolution of PPD. Treatment of the underlying CVD was performed in 18 patients resulting in complete or partial resolution in 17 (94.4%). In seven patients (11.1%), no CVD or haemostatic abnormalities were identified, and the risk factors included dietary factors such as excessive caffeine or soft drink consumption.

Conclusion

Haemostatic abnormalities and CVD contribute to the pathogenesis of PPD. Resolution of PPD in the vast majority of patients may be achieved by cessation of modifiable risk factors and in particular platelet-modifying drugs or supplements and treatment of the underlying venous disease.

Chronic venous insufficiency: Part 1 Pathophysiology and Clinical features

Chronic venous disease (CVD) is a commonly encountered disease in dermatology out-patient department and if untreated, may progress to chronic leg ulcer causing serious morbidity to the patient. Also, it affects the quality of life of the affected patient and contributes to the loss of work productivity. The range of clinical manifestations is myriad, ranging from asymptomatic varicose veins and pigmentation to ulceration and scarring. The awareness of spectrum of clinical presentations is required to identify, diagnose and manage CVD. Long standing cases may develop ankle joint stiffness, significant fibrosis causing fixed flexion deformity, periostitis and even, Marjolin's ulcer. Increased venous hypertension, thought to result from incompetent valve and failure of calf muscle pump, is central to the pathophysiology of the development of CVD. Tissue edema, hypoxia and subsequent fibrosis are major immediate contributing factors responsible for the clinical manifestations of CVD. Localized, chronic inflammation is now increasingly being recognized as a key player, directly responsible for stasis dermatitis and hypercoagulable state. The complete ramifications of persistent inflammation in CVD is yet to be understood and serious systemic morbidities like arterial and cardiac disease are increasingly been recognized in association with CVD.

Pigmented purpuric dermatosis: Ten years of experience in a tertiary hospital and awareness of mycosis fungoides in differential diagnosis

BACKGROUND

Pigmented purpuric dermatoses (PPD) can clinically mimic many diseases. Histopathology provides a definitive diagnosis. The aim of the study is to reveal the features of patients with PPD and to determine the disease frequency in the differential diagnosis, especially mycosis fungoides (MF).

METHODS

We retrospectively reviewed records of patients with PPD admitted to our hospital from January 2010 to May 2019. We studied the histopathological features of 127 patients, and performed pattern analysis on cases with a confirmed histopathologic diagnosis of PPD. Among the cases presenting with clinical features of PPD, but displaying different histopathological diagnoses, we focused on MF and tried to clarify the features of PPD-like MF.

RESULTS

Overall, 389 patients were admitted to our hospital with PPD symptoms. Of them, 262 patients were diagnosed clinically and a histopathological examination was performed in 127 patients. Of 127, 87 were diagnosed with PPD, and in the remaining 40, non-specific features (9.4%), vasculitis (6.2%), pityriasis rosea (4.7%), MF (3.9%), suspected-MF (1.5%), and other dermatoses (%5.5) were detected. The biopsy findings of two patients showed PPD, but during follow-up, the diagnosis of MF was established.

CONCLUSIONS

MF should be included in the differential diagnosis of PPD cases presenting with longstanding and widespread involvement.

A Cross-Sectional Study of Clinico-etiological Profile and Associated Comorbidities in Indian Patients of Pigmented Purpuric Dermatoses

Background:

Pigmented purpuric dermatoses (PPDs) are a group of chronic benign vascular disorders with varied clinical presentation. The etiopathogenesis of the condition largely remains unknown with a paucity of clinico-epidemiological and/or clinico-etiological studies.

Objective:

To study the clinico-epidemiological pattern, etiological factors and associations of PPD and correlate them with its severity in a set of Indian patients.

Materials and Methods:

In a cross-sectional study, all clinically diagnosed and histopathologically confirmed cases of PPD attending the outpatient department of dermatology from November 2015 to October 2016 were included in the study. Patients were evaluated based on a detailed history of the illness, comorbid conditions, drug usage, general physical, systemic, and cutaneous examinations, severity of disease (mild, moderate, or severe), laboratory parameters, and Doppler ultrasonography of the lower extremities.

Results:

There were a total of 60 patients with a female-to-male ratio of 1.14:1. The mean age of patients was 47 ± 12.10 (range: 15–70) years. Majority (70%) of the patients were housewives, bankers, and businessmen. The possible etiological and/or aggravating factors included prolonged standing (28.3%), drug intake (13.3%), alcohol ingestion (10%), strenuous exercise (5%), and varicose vein (3.3%). Schamberg's disease (90%) was the most common type observed. The most common systemic comorbidity identified was hypertension (58.3%) followed by diabetes mellitus (31.6%) and dyslipidemia (28.3%). A positive correlation was found between severity of the disease and presence of comorbidities (Mantel–Haenszel method, P < 0.0001).

Conclusion:

PPD was found to be associated with a variety of disorders and comorbidities. The number of the comorbidities increased with increasing severity of the disease. Besides exposing the patient to various risk factors, this may contribute to the vessel wall damage seen in the condition. All patients with PPD should, therefore, undergo an initial screen for these comorbidities.

Pigmented purpuric dermatoses: analysis of epidemiological, clinical and histopathological aspects in relation to the prognosis of 70 patients, including infants and adults

BACKGROUND

Pigmented purpuric dermatoses (PPDs) are a group of chronic-relapsing, inflammatory purpuras without vasculitis that typically involve the lower limbs. Five major types could be distinguished, according to the clinical and histopathologic analysis. The etiopathogenesis is still unknown and multiple factors have been considered. Prognosis seems not to be influenced by the different clinical forms of PPDs; nevertheless, no previous studies have investigated whether it could be influenced by the anatomical distribution of the disease.

METHODS

We enrolled 70 consecutive patients, including both adults and children with a clinical and histopathological diagnosis of PPD, to investigate possible correlations between the different types of PPDs, their anatomical distribution and prognosis.

RESULTS

We observed that patients, both adults and children, with an uncommon localization of the dermatoses, in particular with a diffuse localization (more than one body area affected), presented more frequently a persistent form of PPDs.

CONCLUSIONS

This is the first study that attempts to relate the anatomical extension of PPDs and their evolution over time. According to our analysis, it seems to be a statistical significance for the prognosis only for patients with Schamberg disease and involvement of lower limbs. However, studies on a larger population are needed.

Venoprotective drugs in pigmented purpuric dermatoses: A case report

Pigmented purpuric dermatoses (PPD) or capillaritis represent a benign condition, presenting with extravasation of erythrocytes in the skin and prominent hemosiderin deposition. The eruption runs a chronic relapsing course and is resistant to therapy. Capillary fragility, cellular immunity, and microvascular inflammation play important roles in the pathogenesis of PPD. Bioflavonoids, currently used as venoprotective agents for the management of chronic venous insufficiency, have been shown to reduce capillary fragility and permeability by inhibiting endothelial cell activation and modulating the leukocyte-endothelium interaction. We report a case of PPD with dramatic improvement consequent to a therapy with a fixed dose combination containing flavonoids like diosmin, hesperidin, and Euphorbia prostata extract along with calcium dobesilate.

A case of lichen aureus successfully treated with 595 nm wavelength pulsed-dye laser

BACKGROUND

Lichen aureus (LA) is a variant of pigmented purpuric dermatosis (PPDs) that typically presents with the acute onset of a solitary, unilateral, purple to rust-yellow colored lichenoid patch or plaque on lower extremities. Treatment remains challenging and is based on anecdotal case reports often with poor results.

AIMS

Describe a case of LA successfully treated with 595 nm wavelength pulsed-dye laser (PDL).

PATIENT/METHOD

A 46-year-old woman with segmental LA was treated using a 595 nm PDL at a uniform spot size of 10 mm, with pulse durations of 10 milliseconds and fluence of 6 J/cm2. The patient had received previous treatments with no improvement.

RESULTS

Clearance was archived after three sessions with PDL. Sessions were performed at intervals of 4 weeks, with no serious adverse events nor recurrence.

CONCLUSION

We hypothesize the favorable clinical outcome with PDL is due to the affinity of the wavelength for oxyhemoglobin (allowing uniform vessel penetration and energy delivery to fragile capillaries and intraluminal blood) and to its anti-inflammatory profile. PDL seems to be an alternative for patients with progressive LA that have failed other therapies.

Pigmentation Disorders in the Elderly

Aging skin is subject to morphological change due to both intrinsic (skin tone, genetics, endogenous hormones) and extrinsic (chronic sun exposure, medications, exogenous pigments) factors. The broad spectrum of transformation includes both hypo- and hyperpigmentation. Although cutaneous pigmentary disorders are common in younger individuals, certain disorders are more prevalent in the geriatric population. This article reviews the epidemiology, pathophysiology, clinical appearance, treatment, and prognosis of pigmentary lesions that are predominant in the elderly.

Diagnostic histochemistry in non-neoplastic skin diseases

Non-neoplastic skin lesions comprise a sizable group of disorders with variable etiologies and clinical manifestations. They can be grouped into vesiculopustular dermatitides; spongiotic and psoriasiform diseases; lichenoid dermatitides; lymphoid infiltrates of the dermis; granulomatous processes; bullous disorders; vasculopathies; panniculitides; deposition disorders; and defects in maintenance of dermal connective tissue. The use of histochemical methods continues to be an indispensable adjunct to conventional microscopy in the further characterization of such lesions. This review considers that topic.

The pathological spectrum and clinical correlation of pigmented purpuric dermatosis-A retrospective review of 107 cases

BACKGROUND

Various pathological findings have been reported in pigmented purpuric dermatosis, but their clinical significance remains unclear.

METHODS

We retrospectively reviewed demographics, clinical presentations, pathological patterns and concurrent systemic diseases among biopsy-confirmed cases of pigmented purpuric dermatosis.

RESULTS

A total of 107 cases were ascertained. Five major pathological patterns were identified: lichenoid (45/107, 42.1%), perivascular (40/107, 37.4%), interface (11/107, 10.3%), spongiotic (7/107, 6.5%) and granulomatous (4/107, 3.7%). Lymphocytic vasculitis was present in 17 patients (15.9%), and Langerhans cell microabscess was seen in 4 (3.7%). Nine patients had partial features mimicking mycosis fungoides but none were confirmed. The lichenoid, perivascular and spongiotic patterns correlated to lichen aureus, Schamberg and eczematoid clinical variants, respectively. The interface pattern was associated with a higher risk of coincident autoimmune diseases (18.2%, P = .0280) and gout (27.3%, P = .0180).

CONCLUSIONS

This study described the wide pathological spectrum of pigmented purpuric dermatosis among Asians. Physicians should be aware about the clinical and pathological variations to facilitate diagnosis.

Epilepsy under my skin?

A 44-year-old male patient was admitted to the hospital for observation after an unwitnessed syncope. Physical examination revealed skin purpura and bilateral tongue haematoma. Laboratory studies were unremarkable. Radiological imaging showed no abnormalities of the vasculature, signs of thrombosis or brain anomalies. Biopsy of a purpuric lesion revealed extravasation of erythrocytes. After excluding several causes of both syncope and purpura, the typical location of these thoracocervicofacial purpura, the tongue haematoma and an elevated prolactin level (which came back later) led to the diagnosis of an epileptic seizure. The patient was referred to the neurology department for follow-up. Within 3 weeks, the purpura were completely resolved, and the patient remained free of seizures during follow-up. In case of an unwitnessed syncope, an epileptic seizure should be carefully considered and thoracocervicofacial purpura can be the pivotal manifestation leading to this diagnosis.

Stasis Dermatitis: Pathophysiology, Evaluation, and Management

Stasis dermatitis commonly occurs in older age. It is caused by venous hypertension resulting from retrograde flow due to incompetent venous valves, valve destruction, or obstruction of the venous system. Further tissue changes arise from an inflammatory process mediated by metalloproteinases, which are up-regulated by ferric ion from extravasated red blood cells. Stasis dermatitis presents initially as poorly demarcated erythematous plaques of the lower legs bilaterally, classically involving the medial malleolus. It is one of the spectrum of cutaneous findings that may result from chronic venous insufficiency. Its mimics include cellulitis, contact dermatitis, and pigmented purpuric dermatoses. Duplex ultrasound is useful in demonstrating venous reflux when the clinical diagnosis of stasis dermatitis is inadequate. Conservative treatment involves the use of compression therapy directed at improving ambulatory venous pressure. Interventional therapy currently includes minimally invasive techniques such as endovenous thermal ablation and ultrasound-guided foam sclerotherapy, which have supplanted the use of open surgical techniques.

Acrally distributed dermatoses: Vascular dermatoses (purpura and vasculitis)

Purpuric lesions appear in acral distribution in a variety of conditions and often provide clues to the clinical diagnosis. Purpuric means "hemorrhagic"-that is, the lesions do not blanch from pressure. This review focuses on dermatoses that produce hemorrhagic lesions in acral distribution from the large groups of the vasculitic diseases and their mimics. Cutaneous small vessel vasculitis is confined to the skin, involves mainly postcapillary venules, and has the hallmark manifestation of palpable purpura. Henoch-Schönlein purpura is an immune complex-mediated systemic vasculitis of the small vessels with manifestations from the skin, joints, kidneys, and gastrointestinal system. Only cases where the immune complexes contain immunoglobulin A type are classified as Henoch-Schönlein purpura. Cryoglobulinemic vasculitis is induced by the deposition of cold-precipitated immune complexes in the small vessels. Urticarial vasculitis comprises a spectrum of conditions with the characteristic course of chronic urticaria, with wheals that persist longer than 24 hours, leave hyperpigmentation, and have leukocytoclastic vasculitis on histologic examination. Polyarteritis nodosa is a rare multisystem, segmental necrotizing vasculitis of mainly the medium-sized vessels. Pigmented purpuric dermatoses are chronic benign dermatoses characterized by petechiae, purpura, and increased skin pigmentation. The hallmark of pigmented purpuric dermatoses is their orange-brown, speckled, cayenne pepper-like discoloration.

Recurrent purpura due to alcohol-related Schamberg's disease and its association with serum immunoglobulins: a longitudinal observation of a heavy drinker

Background

It is unusual for purpura to emerge as a result of drinking alcohol. Such a peculiarity was observed in a 55-year-old man with a 30-year history of heavy alcohol use.

Case presentation

The Caucasian patient was studied for 11 years during several detoxification treatments. During the last 2 years of that period, purpuric rashes were newly observed. The asymptomatic purpura was limited to both lower limbs, self-limiting with abstinence, and reoccurring swiftly with alcohol relapse. This sequence was observed six times, suggesting a causative role of alcohol or its metabolites. A skin biopsy revealed histological features of purpura pigmentosa progressiva (termed Schamberg’s disease). Additionally, alcoholic fatty liver disease markedly elevated serum immunoglobulins (immunoglobulin A and immunoglobulin E), activated T-lymphocytes, and increased C-reactive protein. In addition, moderate combined (cellular and humoral) immunodeficiency was found. Unlike the patient’s immunoglobulin A level, his serum immunoglobulin E level fell in the first days of abstinence, which corresponded to the time of purpura decline. Systemic vasculitis and clotting disorders were excluded. The benign character of the purpura was supported by missing circulating immune complexes or complement activation. An alcohol provocation test with vinegar was followed by the development of fresh “cayenne pepper” spots characteristic of Schamberg’s disease.

Conclusions

This case report demonstrates that Schamberg’s disease can be strongly related to alcohol intake, in our patient most likely as a late complication of severe alcoholism with alcoholic liver disease. Immunologic disturbances thereby acquired could have constituted a basis for a hypersensitivity-like reaction after ingestion of alcohol. Schamberg’s disease induction by vinegar may point to an involvement of acetate, a metabolite of ethanol.

Early treatment with rutoside and ascorbic acid is highly effective for progressive pigmented purpuric dermatosis

BACKGROUND AND OBJECTIVES

Progressive pigmented purpuric dermatosis (PPPD, Schamberg disease) is a rare benign, but chronic dermatosis frequently misdiagnosed as vasculitis or bleeding disorder. Although affected patients experience significant impairment in quality of life no effective treatment has been established. The aim of our two center case series was to evaluate efficacy and tolerability of the antioxidants rutoside and ascorbic acid as combination treatment for PPPD.

PATIENTS AND METHODS

A retrospective review was performed on 35 patients with PPPD treated with 2 × 50 mg rutoside and 1,000 mg ascorbic acid daily between 2004 until 2011. The mean treatment duration was 8.2 months.

RESULTS

71.4% of the participants experienced complete clearance and 20.0% an improvement of more than 50%, accompanied by increased quality of life. Nine participants (25.1%) relapsed after discontinuation. In seven, rutoside and ascorbic acid was re-initiated, and all responded again. Only three participants reported mild adverse effects. Participants with shorter disease duration showed better therapeutic success, shorter time to response and lower risk of recurrence.

CONCLUSION

Oral rutoside and ascorbic acid may be an efficient and well tolerated treatment for PPPD. Early treatment is recommended to achieve best clinical outcome.

Characteristics and Clinical Manifestations of Pigmented Purpuric Dermatosis

Background

Pigmented purpuric dermatoses (PPD) are a spectrum of disorders characterized by a distinct purpuric rash. Although PPD can be easily diagnosed, the disease entity remains an enigma and a therapeutic challenge.

Objective

The purpose of this study was to investigate the characteristics and clinical manifestations of PPD and to elucidate the relationship between assumed etiologic factors and the clinical manifestations of PPD and treatment responses.

Methods

Retrograde analyses were performed to identify appropriate PPD patients who visited Korea University Medical Center Anam Hospital from 2002 to 2012.

Results

Information on 113 patients with PPD was analyzed, and 38 subjects with skin biopsy were included for this study. Schamberg's disease was the most frequent clinical type (60.5%). Concomitant diseases included hypertension (15.8%), diabetes (10.5%), and others. Associated medication histories included statins (13.2%), beta blockers (10.5%), and others. Possibly associated etiologic factors were recent upper respiratory infection (5.3%), high orthostatic pressure due to prolonged standing (2.6%), and strenuous exercise (2.6%). A total of 36 patients (94.7%) were treated with one or more treatment methods, including oral antihistamines, pentoxifylline, topical steroids, and/or phototherapy. There was no significant difference in disease progress according to underlying diseases, medications, or association factors (p>0.05).

Conclusion

Our overall results were grossly consistent with the existing literature, excluding several findings. Although a possible relationship between PPD and cardiovascular disease or cardiovascular medication was proposed at the beginning of the study, no statistically significant correlations were found according to the specific clinical types and treatment responses (p>0.05).

Pigmented purpuric dermatosis: clinicopathologic characterization in a pediatric series

Pigmentary purpuras (PPs) are a group of chronic disorders of unknown origin seldom described in children. With this study we sought to better characterize PP eruptions, including clinical evolution and management. A retrospective chart review from 2003 to 2013 querying characteristics of children with a biopsy-proven diagnosis of PP in the Centre Hospitalier Universitaire Ste-Justine dermatology clinic (Montreal, Quebec, Canada) was performed. Follow-up was obtained through telephone interviews. Descriptive statistical analysis was used. Of the 17 subjects, 8 were male and the mean age of onset was 9 years. PP was asymptomatic in 11 patients, pruritic in 3, and of cosmetic concern in 3. Schamberg's disease was the most frequent subtype in 12 cases. Resolution of PP was found in 13 cases with a median duration of less than 1 year (range 6 months-9 years). Five patients experienced spontaneous clearing without treatment, and improvement was observed in 75% of cases treated with topical corticosteroids and 100% with narrowband ultraviolet B (nbUVB). No associated disease, significant drug exposure, or contact allergens were found. Those findings support that PPs in children are idiopathic, chronic eruptions that can benefit from watchful waiting, although topical corticosteroids or nbUVB are may be useful if the patient or family desires faster resolution. This study was limited by its small size, its retrospective nature, and selection and recall bias.

Dermatologic manifestations of diabetes mellitus: a review

Diabetes mellitus affects every organ of the body including the skin. Certain skin manifestations of diabetes are considered cutaneous markers of the disease, whereas others are nonspecific conditions that occur more frequently among individuals with diabetes compared with the general population. Diabetic patients have an increased susceptibility to some bacterial and fungal skin infections, which account, in part, for poor healing. Skin complications of diabetes provide clues to current and past metabolic status. Recognition of cutaneous markers may slow disease progression and ultimately improve the overall prognosis by enabling earlier diagnosis and treatment.

Pigmented purpura dermatosis and viral hepatitis: a case-control study

Pigmented purpuric dermatosis (PPD) is characterized by petechial and pigmented macules on the lower limbs. The aetiology of PPD remains obscure. Some reports have suggested an association between PPD and hepatitis B or C infection. This prospective case-control study was designed to investigate the association of positive hepatitis B or C serology with PPD. A total of 60 PPD patients and 230 randomly selected controls were enrolled. Sera from all patients and controls were tested for liver function tests (LFT), hepatitis B surface antigen (HBS Ag), and hepatitis C virus antibody (HCV Ab). The prevalence of HBS Ag in patients with PPD and the controls was 3 per cent (5/60) and 4.3 per cent (10/230), respectively. The prevalence of HCV Ab was 1.7 per cent (1/60) and 1.3 per cent (3/230) among patients and controls, respectively. No statistically significant difference was noted in the prevalence of positive hepatitis B or C serology (P-values 0.73 and 0.58, respectively). No statistically significant difference in LFT was observed between the two groups. Therefore, the authors believe it is unlikely that HBV or HCV are directly involved in the pathogenesis of PPD.

Clinicoepidemiological study of pigmented purpuric dermatoses

BACKGROUND

Pigmented purpuric dermatoses (PPD) are a group of vascular disorders with varied manifestations which cause concern and are resistant to treatment. The literature is still lacking in clinicoepidemiological studies.

AIM

To study the epidemiology, etiological, host and environmental factors, clinical manifestations, its variations, and the type prevalent in this part of the world.

MATERIALS AND METHODS

All cases of PPD were selected for the study from Skin and Venereal Disease, Out Patient Department between January 2008 and June 2009. Their history, examination, hematological investigations, and, in a few, histopathology findings were also recorded and data obtained were evaluated statistically.

RESULTS

There were 100 cases of PPD of total 55 323 patients (0.18%). There were 79 males and 21 females between 11 and 66 years. They were working as police men, security guards, barber, chemist, teachers, students, farmers, businessmen, and housewives. In a majority, there was a history of prolonged standing in day-to-day work. Purpuric, brownish pigmented, lichenoid or atrophic lesions were seen depending upon the type of PPD on lower parts of one or both lower limbs. Blood investigations were normal. Schamberg's disease was seen in ninety five, Lichen aureus in three, lichenoid dermatosis and Majocchi's disease in one case each.

DISCUSSION

Three clinical types of PPD were diagnosed which may represent different features of the same disease. Cell-mediated immunity, immune complexes, capillary fragility, gravitational forces, venous hypertension, focal infection, clothing, contact allergy to dyes, and drug intake have been incriminating factors in the past. Patient's occupation and environmental factors may also be considered contributory in precipitating the disease.

CONCLUSIONS

The study revealed the problem of PPD in this geographical area, its magnitude, clinical presentation, the type prevalent, and possible aggravating factors to be kept in mind while managing the disease.

Granulomatous variant of pigmented purpuric dermatosis

Granulomatous pigmented purpuric dermatosis is a rare entity. Historically, it has been seen in Asians. In this article, we report the case of a white man with this unusual variant. A 65-year-old, white man presented with a 1-year history of asymptomatic purpuric to brown papules on both lower legs and more confluent on dorsum of feet. He had an underlying history of hypertension and hyperlipidemia. Skin biopsy revealed a granulomatous lympho-histocytary inflammatory infiltrate in papillary dermis and superficial reticular dermis with extravasation of red blood cells and siderophages. Periodic acid schiff (PAS), Giemsa and Ziehl-Neelsen stains were negative. A diagnosis of granulomatous pigmented purpuric dermatosis was made. From the 10 cases reported of this granulomatous variant, 6 were associated with hyperlipidemia. We report an additional case with this association.

Granulomatous variant of chronic pigmented purpuric dermatoses: report of four new cases and an association with hyperlipidaemia

Four patients presenting with chronic pigmented purpuric dermatosis (CPPD) on the limbs were found to have granulomatous inflammation superimposed on the pathological changes of CPPD. Three of the four patients had hyperlipidaemia. Therefore, the granulomatous reaction observed could be associated with hyperlipidaemia. Whether it occurs only in Asian people or not needs further observation.

Capillarite purpurique généralisée traitée par PUVAthérapie chez un enfant

BACKGROUND

Chronic pigmented purpuric dermatitis includes various entities seen above all in adults, although they may occasionally appear in children. The various therapies available are generally unsuccessful. We report the case of a child who responded dramatically to PUVA therapy.

CASE REPORT

A 10-year-old Caucasian boy of phototype III was evaluated for a one-month history of progressive eruption on the upper extremities, followed by spread to the trunk and the lower extremities. On examination, he had generalized red-yellow lesions with "cayenne-pepper" spots. Extracutaneous examination showed no abnormal features. A skin biopsy showed a superficial, perivascular mononuclear inflammatory infiltrate with extravasations of red blood cells. The laboratory findings were normal. PUVA therapy was given three times weekly. After 4 weeks of PUVA (21 J/cm2) the lesions cleared up. The patient was still free of lesions after 3-years of follow up.

DISCUSSION

The clinical and histological findings in our case were consistent with Schamberg's purpura, a rare disease but nevertheless the most common form of pigmented purpura in children. Schamberg's purpura in children is a chronic disease that can persist for up to 7 years in the absence of treatment, although spontaneous remission may occur within 1 to 4 years. Phototherapy with PUVA and UVB-TL01 has been shown to be efficacious in various forms of pigmented purpuric dermatosis in adults, but only in isolated cases. To our knowledge, this is the first pediatric case of successful PUVA therapy in this disease.

Cutaneous Pseudovasculitis

Cutaneous pseudovasculitis represents a heterogeneous collection of disorders that are capable of simulating cutaneous vasculitis and can be broadly classified into diseases that produce hemorrhage (petechiae, purpura, and ecchymoses) or vessel occlusion with resultant livedo, cyanosis, ulcers, digital necrosis, and/or gangrene. Overlap is not uncommon, but if present, one mechanism dominates. Hemorrhagic pseudovasculitis is due to vessel wall dysfunction (incompetence), which can be related to diverse factors that include vessel wall deposition of metabolic substances (amyloid, calcium), nutritional deficiencies (scurvy), nonvasculitic inflammatory purpura (pigmented purpuric dermatitis, arthropod, viral and drug reactions), degeneration of the vessel wall and supporting stroma (senile/solar purpura), direct vessel wall invasion of infective organisms, coagulation-fibrinolytic disorders (eg, thrombocytopenia), and vessel wall trauma. Cyanotic-infarctive pseudovasculitis is due vaso-occlusion by emboli, thrombi, or fibrointimal hyperplasia (endarteritis obliterans) and includes varied conditions such as purpura fulminans, Coumadin necrosis, antiphospholipid antibody syndrome, cardiac myxoma, cholesterol embolization, calciphylaxis, and radiation arteritis. Delayed and inappropriate diagnosis of pseudovasculitis leads to incorrect management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. The diagnosis of a pseudovasculitic disorder requires a high index of suspicion and should always be part of the differential diagnosis of vasculitis. Skin biopsy is a crucial step in differentiating pseudovasculitis from authentic vasculitis; absence of histologic evidence of vasculitis, particularly after multiple biopsies, should direct evaluation and diagnosis towards pseudovasculitis.

[Atypical clinical presentation of pigmented purpuric dermatosis]

The term pigmented purpuric dermatosis (PPD) is used for a group of mainly asymptomatic, sometimes pruritic dermatoses that are clinically characterized by an eruption of pinpoint purpuric lesions along with yellow, orange, red and/or brown, often patchy pigmented areas. Traditionally five subtypes have been distinguished, but atypical clinical patterns may also occur. Because of the variable clinical spectrum and the similar histopathologic findings, a strict nosological classification is sometimes difficult or even impossible to achieve. We report a case of PPD with atypical clinical features in a young woman, underlining the difficulties in the clinical classification of this spectrum of diseases.

Líquen aureus "algesiogênico"

Descreve-se caso de líquen aureus em paciente do sexo feminino, com 23 anos de idade que apresentava há dois anos lesão dolorosa, purpúrica, acastanhada tendendo por semelhante a cor de ferrugem e de aspecto liquenóide no antebraço. O exame anatomopatológico revelou denso infiltrado linfo-histiocitário na derme superior papilar, com extravasamento de hemácias. O líquen aureus é relativamente raro, sendo ainda mais raro o sintoma de dor.