Leukemia rashes and bruises

Contents

Bruising in leukaemia VS ordinary bruising

Although bruises from leukaemia are very similar to ordinary bruises, there are a few things you can look out for to help spot the difference:

  1. They occur in unusual places – In cases of leukaemia, quite often bruises will appear in places that you wouldn’t normally expect, especially; the back, legs, and hands.

For children, bruises may start to appear on the face, buttocks, ears, chest, and head.

“I noticed some unexplained bruises on my right hand and lower limbs.”

  1. There are lots of them – It is not unusual to have a few bruises on your body at once, especially if you are an active person. However, multiple bruises without explanation is a reason for concern.

“I counted 40 bruises on my body; I just thought I bruised easily.”

  1. You can’t explain why they are there – The bruises may appear without any clear reason. In other words, bruising without damage to that part of the body. They might also develop after very slight knocks that wouldn’t normally cause a bruise.

“I was bruising where I didn’t remember hitting myself.”

  1. They take longer than usual to disappear – Bruises may last for longer than you would expect or might continue to grow in size.

A normal bruise tends to heal after around two to four weeks. Therefore, if a bruise lasts for more than four weeks, we recommend getting it checked by your GP.

“The bruises tended to sort of keep on bleeding underneath the skin.

  1. You have been experiencing excess bleeding – Since bruising is a form of bleeding (it’s just underneath the skin), unusual bleeding from other areas of the body can also be a sign of leukaemia (e.g. heavy periods, frequent nosebleeds or bleeding gums).

“I was almost constantly bleeding from the mouth and the bruises were all over my body.”

Leukemia Rashes, Infections, and Bruises

1. Petechiae

Leukemia is a type of cancer that affects the blood cells and bone marrow, a tissue inside bones where blood cells are made.

When someone has this disease, the cells normally produced in the bone marrow, such as white blood cells, which fight infection; red blood cells, which carry oxygen throughout the body; and platelets, which help form blood clots, will be crowded out by abnormal leukemia cells.

In addition to symptoms like nausea, fever, fatigue, weight loss, and infections, leukemia can also produce a variety of skin conditions such as bruising, rashes, and bleeding.

“We see a few major categories of skin findings in patients with leukemia,” says Amy Forrestel, MD, director of dermatology at the University of Pennsylvania. “The most common skin condition is bleeding into the skin.”

In other cases, some have no skin conditions, Dr. Forrestel says. “It depends on the type of leukemia. The more aggressive ones that require stem cell therapy or chemotherapy almost always have skin findings.”

Related: Speaking Cancer: A Glossary of Formal and Informal Terms Used to Describe Cancer Tests, Treatment, Patients, and More

Skin & Pressure Sores – Care, Treatment & Prevention after Spinal Cord Injury

Skin sores are the most common and devastating medical complication of spinal cord injury. Also called pressure sores, decubiti, decubitus ulcers, or bedsores, skin sores are more apt to occur after spinal cord iinjuries due to lack of movement and sensation and to changes in circulation.

The social impact of skin problems far outweighs almost all other problems you may encounter. A skin sore can mean several weeks of hospitalization or bed rest in order for the sore to heal. This can mean valuable time away from your job or school.

The most important point, however, is that skin problems are preventable. By eliminating the causes of skin sores and with routine inspection of your skin, skin sores need not happen. You must be responsible for your skin care. You must know the condition of your skin and the early warning signs of skin sores. Skin management cannot be neglected. Skin management is of vital importance to you and your continued ability to function.

Causes

Because your blood flows more slowly after SCI, your healing ability is reduced. In addition, your skin cannot tolerate as much pressure as before. Your skin can now tolerate a minute amount of pressure for a long time, but it can only tolerate great pressure for a short time before the circulatory system is disrupted and a pressure or skin sore results.

The decrease in circulation and lower tolerance for pressure is further aggravated by the lack of sensation after SCI. This lack of sensation means there is no longer a feedback mechanism to tell you that there is a problem – that you have been sitting too long without moving or that you have injured yourself, for example.

The major causes of skin sores are:

  • Prolonged pressure
  • Bruises or scrapes
  • Prolonged wetness on the skin
  • Burns
  • Sitting or lying on hard objects
  • Frostbite

Prolonged Pressure

Prolonged pressure means you sit or lie in the same position long enough to cause symptoms of skin damage. These symptoms can also be caused by any clothing, braces, or hard objects that put pressure on your skin. The first symptom – your warning signal – is a reddened area of the skin. No damage has occurred if you remove the pressure and the redness fades with 15 minutes after the pressure is removed.

Skin damage from pressure usually begins over bony prominences – any place on the body where the bones are close to the skin surface, such as the hip. Bony prominences tend to put pressure on the skin from within. If there is a firm surface on the outside as well, the skin will be pinched between the firm inside bone and the firm outside surface, resulting in a lack of circulation.

Due to the decrease in the rate of circulation that occurs following SCI, there is also less oxygen to the skin. This contributes to a lowering of the skin’s resistance. If the skin is deprived of oxygen due to pressure, the body will try to compensate by sending more blood to the area. This may result in swelling, which will put even further pressure on the blood vessels and further block circulation.

You have seen the impression left on a carpet after a chair was moved, and you know that the carpet will get a hole in it if the chair is not moved every so often. This same process happens a lot faster in people than in carpets. Pressure forces blood out of the tiny blood vessels, which nourish the skin and the tissue under the skin. The pressure is most likely to cause damage over bony parts of your body.

Bruises or Scrapes

Bruises or scrapes can occur as a result of a bump or fall. Other causes are ramming your feet into doors or walls or dragging your buttocks while transferring. Because of the lack or decrease of sensation, you may not realize that an injury has occurred. Because of the changes in your circulatory system, you will not heal as quickly and a skin sore may develop.

Prolonged Wetness on the Skin

Possible sources of wetness are perspiration, stool or urine. Moisture of any kind can cause chafing, or excoriation, of the skin. Band-Aids may also cause an excessive accumulation of moisture under the protected area. Moisture prolongs the healing process. Prolonged wetness can lead to a loss of layers of skin which may result in a skin sore.

Burns

Burns can occur from heat, friction, chemicals or tape. Possible sources of burns include:

  • Sunburn
  • Hot water, as in a bathtub or shower
  • Hot water pipes
  • Carrying hot foods or placing liquids on your lap
  • Kitchen stove during the cooking process
  • Picking up or touching hot foods or drinks, such as pizza or fried chicken
  • Electrical appliances, such as hair dryers or irons
  • Electric blankets, hot water bottles or heating pads
  • Sunlamps
  • Cigarettes
  • Sitting on hot objects, such as rocks or concrete in the sun
  • Hot pavement
  • Automobile mufflers, tailpipe, exhaust, heater vents that are directed at the feet, seat-belts, steering wheel, upholstery, or any object that can get hot in a car

Friction burns can occur when surfaces rub against a hard surface, i.e. from spasm or sitting in bed at a 45-degree angle. Some chemicals, such as disinfectants, can cause burns, and adhesive tape can also cause burns (use the non-allergic type), “paper tape”.

Sitting or Lying on Hard Objects

Sitting or lying on a hard object can cause a skin sore. Possible sources are:

  • Safety pins,
  • Curlers or bobby pins
  • Buttons on mattresses
  • Buttons on jeans or slacks
  • Bulky seams
  • Objects placed in slacks’ pocket
  • Catheter connectors
  • Catheter clamps
  • Tight pants over catheter tubing

Frostbite

Frostbite can occur as a result of exposure to a cold environment without enough protection. Always dress warmly if you are going to be outside in cold weather. Ice packs are also a source of frostbite if they are not used properly.

Other Things that Increase Your Chance of Getting a Pressure or Skin Sore:

  • Skin wet from sweat, urine or stool
  • Poor nutrition causing anemia (low blood count) and low protein
  • Slouching in bed or in the wheelchair
  • Fevers
  • Bumps or other injuries to the skin
  • Friction to the skin, caused by sliding or being pulled across a surface, or by spasms
  • Clothing, braces, splints, etc., that are too tight
  • Forgetting or neglecting to take care of yourself if feeling depressed or when drinking too much alcohol or abusing drugs
  • Worn out or improper equipment

A skin sore begins as a red area on the skin. This reddened area may or may not feel hard and/or hot. If you have black skin, the area may appear shiny instead of red. At this stage, the progression is reversible. You must remove all pressure from this area until the skin returns to its normal color.

If pressure is not removed, a blister, pimple or scab may quickly form over the hard red area of the skin. This hard red area of skin means that the tissue underneath is dying. At this point, remove all pressure over the area and consult your physician.

In the next stage, a hole or ulcer forms in the dead tissue. Frequently, this dead tissue is small on the skin surface, but large in the deeper tissues. This damaged tissue may extend all the way to the bone.

And finally, there is infection and destruction of the underlying bone.

How a Pressure Sore Develops

Pressure sores are always caused by pressure.

Stages of Pressure Sores, and What to Do

Stage & Signs What to Do Other Information
1. Skin becomes white or lighter in color Do push-ups and keep to your turning schedule so skin is never deprived of its blood supply for a long time
  1. Blood is not getting to the skin because of pressure
  2. This change in skin is seen for a moment when pressure is relieved
  3. To see what this stage is like, hold a glass tightly; notice your fingertips getting lighter from pressure
2. Skin reddens, is warm and may be swollen when pressure is relieved
  1. Stay off red area until all redness is gone
  2. Do NOT rub red area or put anything on it
  3. If you are dark skinned and can’t see redness, feel for warmth with back of fingers
  1. At this point, you can still stop a sore from developing
  2. Redness and warmth caused by blood rushing to the area when pressure is relieved
  3. If redness is not gone 30 minutes after pressure is relieved, it’s a danger signal (too much pressure or pressure for too long was applied)
3. A blister develops over red area. Skin may have a bluish color to it. The blister often opens
  1. Stay off the area
  2. Call your doctor or nurse
  1. This stage occurs if pressure is not completely removed from a red area
  2. At this point the damage is deeper than you can see
4. Center of open sore turns black or brown and/or there is drainage
  1. Stay off area
  2. Cover with a sterile dressing
  3. Call your doctor
  4. Eat foods that are high in protein
  1. This sore may be very deep and is probably infected. You may feel very sick.
  2. If there is much drainage your body loses protein. Protein is needed for healing.

Prevention of Skin Sores

You Can PREVENT Skin Sores. In order to prevent skin sores, you must:

  • Check your whole body frequently
  • Relieve skin pressure
  • Take routine care of your skin

Check your whole body, but pay special attention to bony areas

By inspecting your skin regularly, you can spot a problem at the very beginning. Checking your skin is your responsibility and the way to spot the warning signals of a problem. Don’t just ask someone else how your skin looks. If you need someone to help you check, you must be able to tell him or her what to look for.

  • How Often? — At least twice daily. Morning and evening when dressing or undressing are recommended. Check more frequently if you are increasing sitting or lying times. Checking whenever you change position is recommended.
  • Watch For? — Any areas previously broken and healed over – scar tissue breaks easily.
  • What Are You Looking For? — Redness, blisters, opening in skin, rashes, etc. Feel for heat in red areas with the back of your fingers.
  • Equipment Needed? — Long-handled mirrors. If you need help, ask someone to position mirrors for you – one at the head and one over the pressure point.

Skin Check

  • Which Parts To Check? — Check the following places on the front, back, and sides of your body. Remember: Bony areas of the body are the most likely to get sores, so be sure and look at them. When checking you skin, don’t forget your groin areas for rashes or sores from tight clothing. Men who wear an external catheter should check the penis carefully for sores or irritations.

Relieve Skin Pressure

In addition to routinely checking your skin, a second important way to prevent pressure sores is to relieve skin pressure by changing position or being positioned so that pressure is taken off a bony area. The purpose of relieving pressure is to let the blood supply get to the skin. If pressure is not relieved, blood will continue to be pressed out of a blood vessel and will not get to the skin to keep it healthy.

How to Relieve Skin Pressure from the Foot

Positioning of the foot and heel.

Pillows can be used for offloading heel pressure in bed. It is recommended that pillows be placed length-wise under the calf to completely elevate the heel off the supporting surface.

Devices made of sheepskin, splints and bunny boots are all acceptable for offloading pressure. These devices pad the heel and prevent friction and shear.

How to Relieve Skin Pressure in Bed

Turning Schedule

Use a turning schedule that does not allow redness to appear on bony prominences. Depending on your body type, you will tolerate a turning schedule of two to five hours (turning from side to back to side). The length of time between turns can be gradually increased by adding 30 minutes to the amount of time in a given position and then checking for redness.

You will be asked to provide an alarm clock or some other means of awakening yourself for position changes during the nighttime. Ultimately, it will be your responsibility to either independently position yourself or verbally direct your caregiver to perform the task.

The only exception to a turning schedule is lying prone (on your abdomen).

Prone Position Padding

You can safely lie prone for up to eight hours by using plump, firm pillows and small foam pads.

  • Head — Small, foam support under head. Size of foam depends on individual comfort. Cover support with materials that are not irritating to your skin.
  • Chest — Use one or more pillows according to comfort.
  • Thighs — Foam pads placed above the knees to prevent redness of knees.
  • Shins — Pad(s) or Pillow(s) under shins to elevate feet height enough to avoid pressure on toes (helps prevent ingrown toenails). An alternative is to allow toes to hang off the end of the bed. Feet should be at right angle to the legs per illustration above.
  • Between Knees — Pads placed between knees to keep knees and ankles apart so pressure sores do not develop.

Warning: Do not substitute folded towels or blankets for foam padding or pillows. These can be too firm and cause skin breakdown.

Sleeping prone at night is very important for two reasons:

  • Both you and whoever helps you to change your position can have a restful eight hours sleep without interruptions.
  • Lying prone straightens your hips and helps prevent tightness of the hips and knees.

Alternate positions are side-to-side positioning as well as supine (back) position. Which position works to your benefit will be determined individually.

Side Position Padding


Position Padding with pillow behind the back.

  • Head — Small, foam support under head. Size of foam depends on individual comfort. Cover support with materials that are not irritating to your skin.
  • Back — Support behind back to maintain side position. Be sure bottom hip is pulled back to prevent rolling backwards on sacrum.
  • Hips — Pad placed above and below the hip joint. When pads are placed correctly, a flat hand can be slid between the body and the bed to be certain that pressure has been relieved. If the pressure has not been relieved, an additional pad can be added.
  • Ankle — Pad placed above the ankle joint.
  • Between Lower Legs — Pillow placed lengthwise between legs to prevent pressure on the knees and ankle joint. Do not have legs directly on top of each other.

Warning: Do not substitute folded towels or blankets for foam padding or pillows. These can be too firm and can cause skin breakdown.

Supine (Back) Position Padding

  • Head — Small, foam support under the head. Size of foam depends on individual comfort. Cover support with materials that are not irritating to your skin.
  • Back — Place pad under lower back to provide elevation of the sacrum (tailbone). This will relieve pressure on the sacral area and relieve muscle tiredness in the back.
  • Knees — The bend at the knee is a natural curvature. Use a pad above the area behind the knee. The pad must not be in the area behind the knee.
  • Ankles — A small pad is necessary at the back of the heel to relieve tension on the calf of the leg. Also, the heels must be off the bed to prevent skin breakdown.
  • Feet — A soft foot support is placed to allow simulation of weight bearing on the ball of the foot.
  • Between Lower Legs — Foam pad or pillow placed between the knees to present possible breakdown at the knee and ankle joints.

Warning: Do not substitute folded towels or blankets for foam padding or pillows. These can be too firm and can cause skin breakdown.

How to Relieve Skin Pressure in a Wheelchair

Weight Shifts:

Weight shifts are the most essential techniques for preventing pressure on the skin and muscle of the sacrum (tailbone) and each hip. Use the method you and your therapists have found to be the most effective for you. Know your skin tolerance at all times. The frequency with which you do weight shifts vary from time to time.

Cushions:

A cushion for your wheelchair is essential. Cushions provide pressure relief and weight distribution and thus aid in the prevention of pressure sores. Many types of cushions exist, but there is no “ideal” cushion. Use the cushion recommended by your physical therapist/physiatrist.

  • If air is used in the cushion, check to see that it is filled correctly. If you are going to a different altitude, there will be a change in your cushion.
  • If your cushion is made of foam, check to see that it is firm and in good condition. If it gets dry, powdery and loses its firmness, replace it immediately. Use only good quality foam. Polyurethane foam with a density of 1.2 and compression of 30 to 35 is recommended.
  • In case of body weight change, you may need to change the width of your chair, the frequency of your weight shifts, and the type of cushion you use.

Never use rubber air rings or rubber doughnuts. They are dangerous because they block the flow of blood to the skin inside the leg.

Weight shifts are essential. The cushion alone will not prevent pressure sores.

In Addition:

  • Make sure the foot pedals of your wheelchair are adjusted to the right height for you. If your foot pedals are too high, it will put pressure on your hips;
  • Sit up straight in your chair. Slumping or slouching leads to added pressure over the end of your tailbone.
  • Lean to One Side

Take Routine Care of Your Skin

The third way to prevent skin sores, the most serious problem in SCI, is to keep your skin healthy. Health skin is skin which is intact, well lubricated with natural oils, and nourished by a good blood supply. Skin stays healthy with good diet, good hygiene, regular skin inspection, and regular pressure relief. We’ve already discussed skin inspection and pressure relief. We’ll focus here on hygiene and nutrition.

Hygiene -You must keep your skin clean and dry. Skin which is frequently moist from urine, sweat, or stool is more likely to break down. Dry skin well after bathing, but don’t rub hard with a towel as rubbing can damage the skin. You may have heard that alcohol massages over bony areas are good for you. They are not. Alcohol dries out your skin and dried, cracked skin is not healthy. If back rubs help you to relax, a gentle one with lotion should be given.

Diet and Fluids – Adequate fluids and a well-rounded diet provide nourishment to the skin. With a good diet containing protein, iron, and vitamins, your skin gets what it needs to stay healthy.

More Tips to Prevent Skin Sores:

Do:

  • Make sure your wheelchair foot pedals are adjusted to the right height
  • Use a prescribed cushion on wheelchair seat
  • Sit up straight in wheelchair (slumping or slouching leads quickly to early skin breakdown over tailbone)
  • Check feet carefully when wearing new shoes – shoes should not be too tight or too large
  • Apply support hose and Ace wrap evenly so that they don’t wrinkle and cause extra pressure
  • Keep skin clean and dry – urine allowed to stay on the skin can lead to problems
  • Use a firm (not hard) mattress, which provides support for your body. Foam mattress over regular mattress helps to spread weight a little more evenly.
  • Lie prone to keep hips stretched out. Also, this position spreads pressure more evenly and there is less chance to get sores
  • Do your wheelchair push-ups or weight shifts every 15 minutes
  • Stick to your turning schedule
  • Use lubricating cream if you have dry skin
  • Remember: even tiny shifts of position help somewhat

Do Not:

  • Use a rubber air ring or any kind of doughnut – they create a lot of pressure where you don’t want it, and block the flow of blood to skin inside the ring.
  • Wear sanitary belts – they can lead to pressure sores.
  • Wear clothing with heavy seams, nylon underwear or tight clothing.
  • Put articles in pants pockets or on seat of wheelchair.
  • Use alcohol on dry skin.
  • Sit in bed with the head raised for long periods – this causes skin to be squeezed over the lower end of the spine and can lead to sores

Majority of this content is from: PoinTIS

What Causes Petechiae?

Petechiae are a sign of blood leaking from capillaries under your skin. Capillaries are the tiniest blood vessels that connect arteries to veins. They help move oxygen and nutrients from your bloodstream to your organs and tissues. They also carry waste away from your organs and tissues.

Leaking in the capillaries could be due to an illness or a medicine you take. Petechiae may also form on your face, neck, or chest if you strain intensely or for a long time when you do things like:

  • Cough hard
  • Vomit
  • Give birth
  • Lift heavy weights

Many infections with bacteria, viruses, or fungi can cause these spots, too, including:

  • Viral infections like cytomegalovirus (CMV), endocarditis, mononucleosis, and the flu
  • Bacterial infections such as meningitis, Rocky Mountain spotted fever, scarlet fever, and strep throat
  • Henoch-Schonlein purpura, a disease that causes inflammation in the small blood vessels
  • Sepsis, a serious, body-wide response to an infection
  • Viral hemorrhagic fevers like dengue, Ebola, and yellow fever

Blood and immune disorders can also cause petechiae, such as:

  • Hemolytic-uremic syndrome (HUS), a group of blood disorders
  • Idiopathic thrombocytopenic purpura (ITP), an immune disorder that affects blood clotting
  • Leukemia, a type of blood cancer
  • Thrombocytopenia, low levels of platelets that help your blood clot
  • Vasculitis, or blood vessel inflammation

A lack of vitamin C (scurvy) or vitamin K in your diet can also lead to petechiae.

Reactions to certain medicines can cause these spots, too. Petechiae may be a side effect of drugs like:

  • Penicillin, an antibiotic
  • Quinine (Qualaquin), a malaria drug
  • Phenytoin and valproic acid, which are seizure medications

Exercise-induced vasculitis

What is exercise-induced vasculitis?

Exercise-induced vasculitis is a harmless form of cutaneous small vessel vasculitis. It is also called golfer’s vasculitis.

It is a neutrophilic inflammatory disorder involving the small or medium-sized blood vessels of the skin and subcutaneous tissue.

When only the small capillary vessels are involved, it is also called exercise-induced capillaritis.

What are the clinical features of exercise-induced vasculitis?

Exercise-induced vasculitis mainly affects one or both lower legs and thighs, with single or multiple episodes of a rash with the following characteristics:

  • Involvement of exposed skin and sparing of skin protected by socks or stockings
  • Red patches, urticarial lesions (weals) and purpura (purple spots)
  • Oedema (swelling) of the affected leg(s)
  • Intense itching, stinging, pain or burning

The patient is otherwise well, without fever, malaise or other symptoms.

Lesions resolve over 3 to 4 weeks. A purplish-brown mark may persist for longer.

Who gets exercise-induced vasculitis?

Patients that present with exercise-induced vasculitis are often female and over 50 years of age. They are most often otherwise healthy and active.

Common activities which can trigger exercise-induced vasculitis include:

  • Jogging and running, especially long-distance running
  • Hiking and climbing
  • Step aerobics
  • Body building
  • Golf
  • Swimming

It is also suspected that there might be a genetic or familial factor causing susceptibility to exercise-induced vasculitis.

Differential diagnosis of exercise-induced vasculitis

Other forms of cutaneous or systemic vasculitis may be aggravated by exercise but are not primarily due to exercise. In these cases, the vasculitis may be due to an underlying disease or condition. Exercise-induced capillaritis generally presents with milder clinical features.

What causes exercise-induced vasculitis?

As the name implies, exercise-induced vasculitis is typically induced by strenuous muscle activity, particularly during warm and humid weather. It is thought that the temperature regulation mechanisms within the calf muscles break down, leading to reduced venous return and blood stasis. The end result is inflammation and vascular injury.

How is exercise-induced vasculitis diagnosed?

Diagnosis of exercise-induced vasculitis can be difficult. It is based on history and physical examination. Some people may undergo investigations, such as:

  • Laboratory tests
  • Imaging, eg X-rays and ultrasound scans
  • Skin biopsy

Laboratory tests and imaging are undertaken for 2 main reasons.

  1. To exclude another cause of cutaneous vasculitis
  2. To determine if other organs are affected, thus diagnosing systemic vasculitis.

Skin biopsy shows leukocytoclastic vasculitis in exercise-induced vasculitis. Direct immunofluorescence examination of new lesions shows complement and immunoglobulins in walls of the blood vessels.

What is the treatment for exercise-induced vasculitis?

Management of exercise-induced vasculitis involves:

  • Temporary cessation of vigorous exercise.
  • Elevation of affected limb(s)
  • Compression stockings to relieve discomfort and speed up healing. They may possibly help prevent exercise-induced vasculitis.
  • Nonsteroidal antiiflammatory drugs and antihistamines to reduce symptoms of burning and itch.

Patients with recurrent episodes of exercise-induced vasculitis should avoid vigorous exercise in warm weather. Although there are no reports of their use in exercise-induced vasculitis, active treatments that can control small vessel vasculitis include:

  • Colchicine
  • Dapsone
  • Hydroxychloroquine

Systemic steroids, eg prednisone, are reserved for severe cutaneous vasculitis eg with blistering or ulceration, and are not necessary for exercise-induced vasculitis.

Patient Education

Petechiae (Child)

Petechiae are tiny (2 mm) red spots on the skin. They are flat on the skin, not raised. They often show up very suddenly. Petechiae usually occur on the arms, legs, stomach, and buttocks. They don’t itch. The spots may be caused by a viral or bacterial infection. They may also be caused by a reaction to a medicine or a collagen disorder. Petechiae that continue to grow and blend together may mean that your child has a bleeding disorder.

Petechiae caused by an infection or medicine go away on their own without treatment. They don’t leave scars. Scattered petechiae with a fever may be the sign of a very serious infection that needs immediate medical care. If a bleeding disorder is causing the spots, the disorder will need to be treated. Your child may need more testing for a diagnosis.

Home care

  • Follow any instructions your child’s healthcare provider gives you. This may include changing a medicine that your child takes. Don’t start or stop any medicines without talking with your child’s provider.

  • Check your child’s spots regularly for changes. The spots may turn purple as they fade and go away.

  • Contact the healthcare provider if you have any questions or concerns about your child’s health.

Follow-up care

Follow up with your child’s healthcare provider, or as advised.

When to seek medical advice

Call your child’s healthcare provider right away if any of these occur:

  • Your child has a fever of 100.4°F (38°C), or as directed by the provider

  • Your child’s condition gets worse in any way

  • The spots increase or get bigger

  • The spots blend together

  • Long streaks appear under your child’s nails

  • Your child has bruising that is unexplained or gets worse

  • Your child shows irritability, such as crying that can’t be soothed

  • Your child becomes lethargic or unusually sleepy, or does not act like normal

  • Your child has breathing problems

An Unusual Petechial Rash

Discussion

The answer is A: Schamberg’s disease. This is an uncommon eruption characterized by progressive, asymptomatic petechiae and patches of brownish pigmentation that may occur in any age range from children to elderly persons. The lesions may occur in any location but most often affect the lower extremities. Characteristic “cayenne pepper” spots appear within and at the edges of old lesions, caused by erythrocytes breaking down outside the capillary and leaving hemosiderin deposits. The skin lesions are nonpalpable macules that may persist for months to years and are typically asymptomatic except for the cosmetic appearance. Males tend to be affected more than females.

The exact etiology is unknown, but a cellular immune reaction may play a role. Occasionally, Schamberg’s disease occurs secondary to a drug reaction, and withdrawal of the medication may improve the lesions.1 Histologic examination shows a lymphocytic vasculitis involving the blood vessels of the upper dermis (i.e., mainly the capillaries), with endothelial swelling and extravasated red blood cells.2

Treatment of these asymptomatic lesions usually is not necessary, but some patients may wish to cover the affected areas with topical cosmetics. If mild itching occurs, topical steroids may be useful. Graduated compression elastic hose may help on the lower extremities, because this condition is thought to be caused by capillary leakage. Laser ablation of lesions has been attempted but has not proved successful.

Henoch-Schönlein purpura is an IgA-mediated hypersensitivity vasculitis that most commonly affects young children but may occur in adulthood. The constellation of symptoms occurring most often with this condition includes a palpable purpuric rash on the lower extremities or buttocks, arthritis, abdominal pain, gastrointestinal bleeding, and renal involvement. This patient was elderly and had no such associated symptoms, making this diagnosis unlikely.

Hypersensitivity vasculitis is a small vessel inflammatory disease mediated by deposition of immune complexes that cause palpable purpuric skin lesions. Prodromal symptoms usually include fever, malaise, myalgia, and joint pains. This type of vasculitis most commonly is caused by a drug reaction, but it also is associated with a number of infectious etiologies, such as hepatitis B and C, human immunodeficiency virus, and endocarditis. The ESR almost always is elevated during active vasculitis.3 Again, this patient had no such associated symptoms, her purpuric lesions were nonpalpable, and her ESR was normal.

Idiopathic thrombocytopenic purpura is a bleeding disorder characterized by low platelet numbers resulting from platelet destruction by the immune system. Skin hemorrhage, easy bruising, abnormal menstrual bleeding, or sudden and severe loss of blood from the gastrointestinal tract may occur. The diagnosis is apparent by a low platelet count and otherwise normal complete blood count. This patient had a normal platelet count.

Contact dermatitis is an inflammatory skin condition. It is unlikely in this patient because there were no signs of skin inflammation on examination and also no subjective symptoms such as pruritus or burning.

Selected Differential Diagnosis of an Unusual Petechial Rash

Condition Characteristics

Schamberg’s disease

Asymptomatic petechiae and patches of brownish pigmentation; cayenne pepper spots

Henoch-Schönlein purpura

Palpable purpuric rash; associated arthritis, abdominal pain, gastrointestinal bleeding, and renal involvement

Hypersensitivity (leukocytoclastic) vasculitis

Palpable purpuric rash; elevated erythrocyte sedimentation rate; prodromal fever, malaise, myalgia, and joint pains

Idiopathic thrombocytopenic purpura

Skin hemorrhage; low platelet numbers

Contact dermatitis

Inflammatory; pruritus and burning

Condition Characteristics

Schamberg’s disease

Asymptomatic petechiae and patches of brownish pigmentation; cayenne pepper spots

Henoch-Schönlein purpura

Palpable purpuric rash; associated arthritis, abdominal pain, gastrointestinal bleeding, and renal involvement

Hypersensitivity (leukocytoclastic) vasculitis

Palpable purpuric rash; elevated erythrocyte sedimentation rate; prodromal fever, malaise, myalgia, and joint pains

Idiopathic thrombocytopenic purpura

Skin hemorrhage; low platelet numbers

Contact dermatitis

Inflammatory; pruritus and burning

Purpuric and petechial rashes in adults and children: initial assessment

  1. Angela E Thomas, consultant paediatric haematologist1,
  2. Susan F Baird, consultant paediatric haematologist1,
  3. Julia Anderson, consultant haematologist2
  1. 1Department of Haematology, Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK
  2. 2Department of Haematology, Edinburgh Royal Infirmary, Edinburgh, UK
  1. Correspondence to: A E Thomas angela.thomas2{at}nhs.net

What you need to know

  • Assess all patients with suspected purpura for features of serious illness

  • If invasive meningococcal disease is suspected, administer parenteral antibiotics immediately, but do not delay hospital admission

  • In all other patients, severe thrombocytopenia must be excluded. Immediately refer children and young people for assessment; adults should have a full blood count and coagulation screen within 48 hours

Bleeding into the skin or mucosa from small vessels produces a purpuric rash, or smaller petechiae (1-2 mm in diameter). Purpura is not a diagnosis but can be the presenting feature of serious conditions, such as meningococcal sepsis and acute leukaemia, which require urgent diagnosis and management. Equally, it can cause patients alarm but requires little more than a single assessment and reassurance. Differentiating between the two scenarios is important. This article focuses on recognition of the serious diagnoses and recommendations for urgent referral. Once such diagnoses have been excluded, other causes can be investigated or the patient managed by observation alone.

Is the rash purpuric?

A cardinal sign of a purpuric rash is that it does not blanch on pressure, unlike exanthema, telangiectases, or allergic rashes. This sign of meningococcal sepsis has been the subject of public health campaigns to help parents recognise its importance and seek urgent medical attention (fig 1⇓).

Fig 1 Petechial rash in invasive meningococcal disease

It is crucial to assess for features of serious illness in all patients with purpura.

What can cause a purpuric rash?

Patients with purpura can generally …

Petechial rash on the extremities

  1. Stephanie St Pierre, medical student1,
  2. Marisa Potter, dermatology resident2,
  3. Scott P Prawer, dermatology resident (graduated), dermatologist23,
  4. Pitiporn Suwattee, assistant professor of dermatology4
  1. 1University of Minnesota Medical School, Minneapolis, MN, 55455 USA
  2. 2Department of Dermatology, University of Minnesota, Minneapolis, MN, 55455 USA
  3. 3Private Practice, Fridley, MN, 55432 USA
  4. 4Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, 55417 USA
  1. Correspondence to: P Suwattee suwat001{at}umn.edu

A 53 year old, afebrile woman presented to the dermatology clinic with a two week history of petechial rash on her lower extremities that had progressed up to her arms. In addition, she also had pain in the wrists, knees, and elbows. Approximately five months earlier, she had been diagnosed with group A streptococcal pharyngeal infection, but she had not been treated with antibiotics. She was currently taking salbutamol, famciclovir, levothyroxine, lovastatin, and varenicline. A systems review was unremarkable and she had no reported haematuria, abdominal pain, or bloody stools.

A physical examination found multiple petechial macules, papules, and purpuric plaques, which were more numerous on the legs than on the arms (figure). A complete blood count and coagulation studies were normal. Urinalysis showed haematuria and proteinuria. A skin biopsy of a petechial papule revealed leucocytoclastic vasculitis, with a granular IgA reactivity around the blood vessels in the papillary dermis.

Questions

  • 1 What additional investigative studies could be useful in a patient with palpable purpura?

  • 2 What is the most likely diagnosis in our patient?

  • 3 What are the adverse sequelae of this disease?

Answers

Short answers

  • 1 Additional studies should include a faecal occult blood test, serology for hepatitis B and C, serum protein electrophoresis, anti-streptolysin O titre, and measurement of antinuclear antibodies, antineutrophil cytoplasmic antibodies, rheumatoid factor, serum immunoglobulins, and cryoglobulins. Abdominal ultrasound and renal biopsy may also be indicated.

  • 2 The most likely diagnosis is Henoch-Schönlein purpura or anaphylactoid purpura, a leucocytoclastic vasculitis of small vessels.

  • 3 Complications of Henoch-Schönlein purpura include nephritis or nephrotic syndrome, acute and chronic renal failure, gastrointestinal bleeding, intussusception, bowel obstruction, and bowel perforation.

Long answers

1 Investigations

Cutaneous palpable purpura may signify small vessel vasculitis, which has many possible causes (box 1).1 2 Histological findings of leucocytoclastic vasculitis include fibrin deposition in the vessel walls, red blood cell …

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