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ULY CLINIC

17 Septemba 2025, 11:30:01

Purpura

Purpura is the extravasation of red blood cells from blood vessels into the skin, subcutaneous tissue, or mucous membranes. Clinically, it presents as easily visible discoloration through the epidermis, typically purplish or brownish-red. Purpuric lesions include petechiae, ecchymoses, and hematomas. Unlike erythema, purpura does not blanch under pressure because the discoloration is due to blood in tissues rather than vessel dilation.

Pathophysiology

Purpura arises from a combination of:

Endothelial damage of small vessels
Coagulation defects
Ineffective perivascular support
Capillary fragility and increased permeability

These defects may result from:

Hematologic disorders (e.g., thrombocytopenia, leukemia)
Invasive procedures
Use of anticoagulants

Nonpathologic causes include:

Aging: Loss of collagen weakens vessel support.
Cachexia: Skin atrophy and subcutaneous fat loss increase susceptibility to trauma.
Mechanical stress: Coughing, vomiting, seizures, or weightlifting can cause localized purpura.
Fever: Increases capillary fragility.

History and Physical Examination

History should include:

Onset, duration, and progression of lesions
Family or personal history of bleeding disorders
Medications (including anticoagulants)
Diet and nutritional status
Recent trauma, procedures, or transfusions
Associated symptoms: epistaxis, gum bleeding, hematuria, hematochezia
Systemic signs suggesting infection or inflammation
For females: heavy menstrual bleeding

Physical examination:

Inspect entire skin and mucous membranes for type, size, distribution, and severity of lesions
Determine lesion morphology (petechiae, ecchymoses, hematomas)
Assess for signs of systemic hemorrhage

Classification of Purpuric Lesions

Type	Characteristics	Typical Location	Clinical Notes
Petechiae	Painless, pinpoint (1–3 mm), red/brown	Dependent areas	Appear in crops; may group to form ecchymoses
Ecchymoses	Larger than petechiae, purple/blue/yellow-green	Anywhere on body	Often traumatic; common on arms/legs in bleeding disorders
Hematomas	Palpable, painful, swollen	Variable	Superficial red, deep blue; >1 cm, size variable

Gender Cue: Purpura is more common in women and in individuals with abundant subcutaneous fat (breasts, abdomen, buttocks, thighs, calves).

Medical Causes

Cause	Laterality	Onset	Key Features	Systemic Signs	Pathophysiology	Management
Autoerythrocyte Sensitivity	Usually unilateral	Abrupt	Painful ecchymoses, local itching/burning	Epistaxis, hematuria, hematemesis, menometrorrhagia, GI symptoms	Immune-mediated RBC hypersensitivity	Symptomatic; corticosteroids if severe
Disseminated Intravascular Coagulation (DIC)	Usually bilateral	Hours–days	Variable purpura; possible purpura fulminans	Bleeding, acrocyanosis, renal failure	Systemic activation of coagulation	Treat underlying cause; supportive care
Dysproteinemias (e.g., Multiple Myeloma)	Variable	Insidious	Petechiae, ecchymoses	Gum bleeding, hematemesis, leg edema	Abnormal plasma proteins affecting hemostasis	Treat underlying hematologic disorder
Easy Bruising Syndrome	Bilateral	Recurrent	Spontaneous bruising	Pain before bruising	Capillary fragility	Symptomatic management
Ehlers-Danlos Syndrome (EDS)	Bilateral	Chronic	Soft, velvety skin, hyperelastic joints, easy bruising	Epistaxis, hematuria	Collagen defect, vascular fragility	Symptomatic; surgical caution
Idiopathic Thrombocytopenic Purpura (ITP)	Scattered	Insidious	Petechiae on distal extremities	Epistaxis, menorrhagia	Autoimmune platelet destruction	Corticosteroids, IVIG
Leukemia	Widespread	Insidious (chronic) / Acute	Petechiae, mucosal bleeding	Fever, fatigue, lymphadenopathy, splenomegaly	Marrow infiltration, thrombocytopenia	Chemotherapy, supportive care
Myeloproliferative Disorders	Variable	Gradual	Ecchymoses, ruddy cyanosis	Headache, pruritus, splenomegaly	Overproduction of blood cells, vascular fragility	Treat underlying disorder
Systemic Lupus Erythematosus (SLE)	Variable	Chronic	Purpura, butterfly rash, alopecia	Joint pain, photosensitivity, fever	Autoimmune vascular inflammation	Immunosuppressive therapy
Thrombotic Thrombocytopenic Purpura	Generalized	Acute	Purpura, pallor, jaundice	Fever, neurologic symptoms, renal failure	Platelet microthrombi	Plasma exchange, immunosuppression
Trauma	Localized	Acute	Ecchymoses, hematomas	Pain, swelling	Direct vessel injury	Supportive care, RICE
Drugs (e.g., Heparin, Warfarin)	Variable	3–10 days after start	Painful purpura, necrotic lesions	Possible bleeding	Anticoagulant-induced coagulation defects	Discontinue drug, supportive care
Procedures & Surgery	Localized	Post-procedure	Ecchymoses, hematomas	Possible systemic bleeding	Mechanical disruption of vessels	Supportive care

Assessment and Diagnostic Workup

Blood tests: CBC, platelet count, coagulation profile (PT, aPTT), fibrinogen, clot retraction
Peripheral smear: Evaluate for abnormal cells
Bone marrow examination: If hematologic disorder suspected
Capillary fragility tests: Assess vessel integrity

Management Principles

Treat underlying cause (hematologic, autoimmune, infectious, or drug-related)
Reassure patients that purpura itself is not permanent
Avoid cosmetic fade creams or unverified topical agents
For hematomas:
- First 24 hours: Cold compress
- After 24 hours: Warm compress to promote absorption

Patient counseling

Emphasize importance of follow-up and treatment adherence
Advise on avoiding trauma that may exacerbate lesions
Educate about signs of systemic bleeding (epistaxis, hematuria, GI bleeding)
For patients on anticoagulants, discuss medication adherence and monitoring

Pediatric considerations

Neonates may show transient petechiae after birth; usually benign
Common childhood purpura: allergic purpura (Henoch-Schönlein), trauma, hemophilia, ITP
High vigilance for child abuse: bruises in unusual locations or multiple stages of healing

References

Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.
McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.
Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.
Wolff K, Johnson RA. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 6th ed. New York, NY: McGraw Hill Medical; 2009.
Buttaro TM, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice, 5th ed. St. Louis, MO: Mosby Elsevier; 2012.