Characteristics and Clinical Manifestations of Pigmented Purpuric Dermatosis

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.

TNF-α inhibitor induced pigmented purpuric dermatoses: a case report

Background

We present a rare case of TNF-α inhibitor induced pigmented purpuric dermatoses (PPD) and explore its mechanisms and management.

Case presentation

A 44-year-old woman presented with non-pruritic non-tender petechial rash on bilateral lower limbs after being started on Adalimumab, with the rash progressing to worsen on Golimumab, both used for managing her seronegative peripheral arthritis. Laboratory panel revealed a negative vasculitis screen and skin biopsy confirmed the condition. After ceasing the TNF-α inhibitors and changing to Secukinumab, an Interleukin-17 inhibitor, the lesions stopped erupting and slowly resolved.

Conclusion

PPD is a benign skin condition and has been associated with various medications and exposure to chemicals in the literature. Different mechanisms have been proposed in the literature however its exact aetiology is unknown. To date, there is no standardized treatment however patients should be reassured that PPD is benign and will often regress by itself once the causative agent has been removed.

Pigmented Purpuric Dermatosis of the Hand: Clinicopathologic Analysis of Six Cases With Review of the Literature

ABSTRACT

Pigmented purpuric dermatosis (PPD) is a group of skin disorders characterized by red, brown, or golden macules and patches with cayenne pepper-like spots. Classic histopathologic features include a perivascular lymphocytic infiltrate with associated erythrocyte extravasation and hemosiderin deposition. Although PPD most commonly affects the lower extremities, upper extremity involvement has been infrequently reported. Cases involving the hands are particularly rare. We present 6 new cases of PPD involving the hand and review 17 previously reported cases in the literature. All cases in our series were unilateral and localized to the dorsum of the hand. PPD was considered clinically in only 2 of these cases. Histopathologic examination revealed hallmark features of PPD, namely a superficial perivascular lymphocytic infiltrate and extravasated erythrocytes. Previous reports of PPD involving the hand described concurrent involvement of other anatomic sites in most cases; only 4 cases (24%) were confined to the hands. Histopathologic descriptions of these reported cases were compatible with PPD. In sum, our series describes a unique and rare clinical presentation of PPD confined to the unilateral dorsal hand. Because of the unusual presentation, biopsy is often required for accurate diagnosis.

Dermoscopic Findings and the Clinicopathologic Correlation of Pigmented Purpuric Dermatosis: A Retrospective Review of 60 Cases

Background

Pigmented purpuric dermatosis (PPD) is known as a chronic recurrent eruption which usually presents with petechiae and pigmented macules on the lower extremities. Dermoscopy is a noninvasive diagnostic tool in identifying pigmented and vascular lesions, which can also be beneficial in the evaluation of PPD.

Objective

We aimed to analyze the common dermoscopic characteristics of PPD, and correlate those findings with the histopathologic features. Additionally, dermoscopic and pathological findings in this study population were compared with other similar studies from the literature review.

Methods

A retrospective analysis was performed using data of 60 patients who were diagnosed as PPD by skin biopsy and had dermoscopic examination. The pathologic analysis was performed by categorizing the pattern into lichenoid, perivascular, interface, and spongiotic subtype, and the dermoscopic assessment was performed by the three authors independently.

Results

In dermoscopy, 96.7% of the patients showed red globules and dots, followed by brownish patch, coppery-red pigmentation, and annular comma-like vessels. The pathologic pattern analysis revealed statistically significant association of lichenoid pattern with coppery red pigmentation, perivascular pattern with annular/comma-like vessels, and spongiosis pattern with reticular pigmented network and linear vessels. The interrater similarity test showed total kappa value of 0.811 which referred to "very good".

Conclusion

In this study, the prevalence of dermoscopic features in Asian PPD patients was identified, which was similar with previous studies. The dermoscopic-pathologic correlation was found in four dermoscopic features. We suggest that dermoscopic examination is helpful in clinical diagnosis and pathological prediction of PPD.

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.

Vasculitis

Vasculitis, characterized by inflammation and necrosis, manifests a wide spectrum of presentation by involving a vasculature of various sizes and locations. A definitive diagnosis of vasculitis invariably requires histologic confirmation since there are no diagnostic clinical, imaging, or laboratory findings. The most widely adopted vasculitis classification is the Chapel Hill Consensus Conference (CHCC) nomenclature of systemic vasculitis which integrated clinical symptoms, histopathologic features, and laboratory findings. This classification accounts for the size of the involved vessels. This chapter outlines the clinical and histologic features of the small-vessel vasculitis including the immune complex vasculitis and antineutrophil cytoplasmic antibody-associated vasculitis; medium-vessel vasculitis such as polyarteritis nodosa and Kawasaki disease; large-vessel vasculitis, namely, giant cell arteritis and Takayasu arteritis; variable-vessel vasculitis such as Behcet disease and Cogan syndrome; and vasculitis associated with systemic diseases including rheumatoid arthritis, lupus vasculitis, and sarcoid vasculitis. Vasculitis can also be secondary to drugs, infection, underlying systemic disease, or trauma. Therefore, a diagnosis of vasculitis cannot be based on histologic ground alone. Clinical pathologic correlation is necessary.

The color of skin: brown diseases of the skin, nails, and mucosa

Brown diseases comprise disorders leading to hyperpigmentation in skin and nails. Melasma is an acquired skin disorder that is characterized by brownish macules that typically occur on the face. Schamberg disease, also known as progressive pigmented purpura, is characterized by brown pigmentation with pepper spots on their edges. We summarize the epidemiology, pathogenesis, histologic features, and treatment choices for additional brown diseases, including melasma, pigmented purpuric dermatoses, postinflammatory hyperpigmentation, drug-induced hyperpigmentation, and pigmentations due to systemic or physiologic conditions.

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.

Diet-induced Pigmented Purpuric Dermatosis Confirmed with a Rechallenge Response

The pigmented purpuric dermatoses (PPDs) are a group of chronic cutaneous eruptions characterized by non-blanching and non-palpable purpuric lesions. Their etiology is not completely understood, although dietary exposures have been implicated in a few case reports. We describe a recurring case of diet-induced PPD in a 73-year-old Caucasian male following the ingestion of tomato-based products on two separate occasions, one year apart. On physical examination, he demonstrated numerous 1-2 mm red/brown, non-blanching, petechial macules scattered on the bilateral anterior lower legs, thighs, trunk, arms, hands, and feet with facial sparing. Histopathologic examination revealed the classic perivascular lymphocytic infiltrate with red blood cell extravasation seen in PPD. Mirroring his first episode, the patient saw a complete resolution of his rashes with careful avoidance of tomato-based products and required no other interventions. This represents a rare case of diet-induced PPD confirmed with a rechallenge response and suggests that acute or recurrent cases of PPD may be a result of a hypersensitivity reaction.

The color of skin: purple diseases of the skin, nails, and mucosa

The color purple can be seen in several types of eruptions including inflammatory dermatoses like lichen planus, infectious dermatoses like ecthyma gangrenosum, neoplasms like Kaposi sarcoma, and vasculitis and vasculopathy. The current review focuses on the clinical appearance, pathophysiology, and treatment of several vasculitides and vasculopathies including capillaritis, cutaneous small-vessel vasculitis, immunoglobulin A (IgA) vasculitis, cryoglobulinemia, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, polyarteritis nodosum, warfarin-induced skin necrosis, heparin-induced thrombocytopenia, purpura fulminans, antiphospholipid antibody syndrome, calciphylaxis, levamisole-induced vasculopathy, and thrombotic thrombocytopenic purpura. Dermatologists play a central role in treating patients with cutaneous vasculitis and vasculopathy and may have the opportunity to facilitate identification of systemic disease by diagnosing cutaneous vasculitis and vasculopathy.

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.

Cutaneous Adverse Effects of Diabetes Mellitus Medications and Medical Devices: A Review

Diabetes mellitus is one of the most prevalent chronic diseases in the USA. If uncontrolled, diabetes can lead to devastating complications. Diabetes medications and medical devices largely contribute to the significant financial expense that the disease inflicts on affected individuals and society. Alongside significant economic burden, there are numerous cutaneous adverse effects associated with diabetes medications and medical devices. Despite the large and increasing number of individuals living with diabetes and the wide use of the related medications and medical devices, there is limited literature that comprehensively documents their cutaneous adverse effects. These cutaneous adverse effects are significant as they can worsen glycemic control, increase disease distress, and may increase risk of associated complications. Thus, it is important that providers can recognize these cutaneous adverse effects, identify the culprit agents, and can properly manage them. In this article, we provide a critical review of the cutaneous adverse effects of medications and devices used in the management of diabetes and provide insight into risk factors and prevention and an overview of therapeutic management. An emphasis is placed on clinical recognition and treatment for use of the medical providers who, regardless of practice setting, will treat patients with diabetes.

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.

Pigmented Purpuric Dermatosis in Adults Treated with Herbal Medicine: Report of Five Cases

BACKGROUND

The purpose of this report is to demonstrate the clinical effect of Korean medicine treatment for pigmented purpuric dermatosis (PPD).

METHODS

Five cases of PPD with skin purpura and blood heat due to blood deficiency were evaluated. All patients had been in a chronic disease state for at least 1 year. The treatment consisted only of the Korean herbal medicine Gami-Samultang (GS). The degree of symptoms that the patients experienced when they first visited our clinic was set at a visual analog scale (VAS) score of 10.

RESULTS

After treatment, body purpura disappeared in all cases. In contrast, the patients' symptoms had not resolved following previous steroid treatment. All patients were satisfied with the treatment results and showed a VAS score of 0 for purpura.

CONCLUSION

This report suggests that GS can be used to effectively treat PPD. Additional clinical studies on PPD are needed to develop more comprehensive treatment guidelines.

Successful Topical Treatment of Pigmented Purpuric Lichenoid Dermatitis of Gougerot-Blum in a Young Patient: A Case Report and Summary of the Most Common Pigmented Purpuric Dermatoses

We report the case of a 12-year-old girl who presented a rash with reddish-brown patches on the trunk and extremities indicative of pigmented purpuric lichenoid dermatitis of Gougerot-Blum (PPLD). The histological findings were characteristic for PPLD, thus supporting the diagnosis. Topically administered corticosteroid led to a fast resolution of all symptoms. PPLD is not seen commonly in young patients and is most often described as responding poorly to treatment with topical corticosteroids. However, the case presented here shows both that PPLD can be seen in adolescence and that the condition may be treated successfully with an intense regime of topical corticosteroids. PPLD belongs to the group of pigmented purpuric dermatoses. The 5 most common pigmented purpuric dermatoses are summarized with respect to their clinical and paraclinical characteristics.