eMedicine Specialties > Dermatology > Diseases of the Vessels

Pigmented Purpuric Dermatitis: Differential Diagnoses & Workup

Author: Darius Mehregan, MD, Associate Professor, Hermann Pinkus Chairman of Dermatology, Department of Dermatology, Wayne State University; Clinical Associate Professor of Pathology, University of Toledo; Dermatopathologist, Pinkus Laboratory; Consulting Staff, Department of Dermatology, J Dingell Veterans Affairs Medical Center
Coauthor(s): Jennifer Michelle Heyl, MD, Resident Physician, Department of Dermatology, Wayne State University School of Medicine
Contributor Information and Disclosures

Updated: Jan 19, 2010

Differential Diagnoses

Drug eruption
Scurvy
Urticarial Vasculitis
Vasculitis

Other Problems to Be Considered

Pigmented purpuric dermatoses must be distinguished from early cutaneous T-cell lymphoma, purpuric clothing dermatitis, stasis pigmentation, scurvy, leukocytoclastic vasculitis, purpuric generalized lichen nitidus,1 and drug hypersensitivity reactions (eg, allergy to rituximab, carbamazepine, meprobamate, bufexamac, chlordiazepoxide, furosemide, nitroglycerin, vitamin B-1, or injection with medroxyprogesterone acetate).2,3,4,5,6,7,8

A case of glipizide-induced pigmented purpuric dermatosis has been reported.9

Topical fluorouracil and eutectic mixture of local anesthetics (EMLA) have been implicated in a pigmented purpuric dermatitislike skin eruption.

Pharmacologically induced regressed Kaposi sarcoma lesions may be misdiagnosed clinically and histologically as pigmented purpuric dermatitis.10

Buckthal-McCuin and Mutasim described macular arteritis mimicking pigmented purpuric dermatosis.11

Workup

Laboratory Studies

  • A complete blood cell count is necessary to exclude thrombocytopenia, and coagulation screening helps to exclude other possible causes of purpura.

Imaging Studies

  • Dermoscopy has been reported to be a useful tool for assisting the clinical diagnosis of pigmented purpuric dermatoses.12

Other Tests

  • Capillary fragility may be assessed by the Hess test.

Procedures

  • A skin biopsy helps to confirm the diagnosis of a pigmented purpuric eruption and aids in excluding cutaneous T-cell lymphoma, which in its early stages may closely mimic a pigmented purpuric dermatitis both clinically and histologically.

Histologic Findings

Histologically, a perivascular infiltrate of lymphocytes and macrophages is centered on the superficial small blood vessels of the skin. Signs of endothelial cell swelling and narrowing of lumina may be seen, as demonstrated in the image below.


Endothelial cell swelling is a histologic feature...

Endothelial cell swelling is a histologic feature of capillaritis. This biopsy sample was obtained from a patient with lichen aureus.

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Endothelial cell swelling is a histologic feature...

Endothelial cell swelling is a histologic feature of capillaritis. This biopsy sample was obtained from a patient with lichen aureus.


The infiltrate is composed of predominantly CD4+ lymphocytes along with occasional CD1a+ dendritic cells. Plasma cells and neutrophils are occasionally present; the latter is not uncommon in lesions of itching purpura. Extravasation of red blood cells with marked hemosiderin deposition in macrophages is typically seen, as demonstrated in the image below. However, the degree of hemosiderin deposition may be variable, and it can be minimal in early lesions of itching purpura.

Hemosiderin deposition is seen in dermal macropha...

Hemosiderin deposition is seen in dermal macrophages in this biopsy sample obtained from a patient with lichen aureus.

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Hemosiderin deposition is seen in dermal macropha...

Hemosiderin deposition is seen in dermal macrophages in this biopsy sample obtained from a patient with lichen aureus.


Histochemical staining with Perls stain and Fontana-Masson stain, to demonstrate iron (hemosiderin) and exclude melanin pigment respectively, may be helpful. Hemosiderin deposition in the dermis is more superficial in pigmented purpuric dermatitis than that seen in stasis dermatitis, which is a useful differentiating feature. Mild epidermal spongiosis and exocytosis of lymphocytes may be seen in all variants except lichen aureus, which, in general, tends to show a bandlike infiltrate separated from the epidermis by a thin rim of uninvolved collagen.

Kerns et al described an unusual variant of pigmented purpuric dermatoses, granulomatous pigmented purpura, in a 42-year-old white woman, and Wong et al reported 2 cases of a similar variant.13,14

More on Pigmented Purpuric Dermatitis

Overview: Pigmented Purpuric Dermatitis
Differential Diagnoses & Workup: Pigmented Purpuric Dermatitis
Treatment & Medication: Pigmented Purpuric Dermatitis
Follow-up: Pigmented Purpuric Dermatitis
Multimedia: Pigmented Purpuric Dermatitis
References
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References

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  30. Saito R, Matsuoka Y. Granulomatous pigmented purpuric dermatosis. J Dermatol. Aug 1996;23(8):551-5. [Medline].

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Further Reading

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Keywords

pigmented purpuric dermatitis, pigmented purpuric dermatosis, pigmented purpuric dermatoses, capillaritis, benign pigmented purpura, pigmented purpuric eruptions, Schamberg disease, progressive pigmentary dermatosis, itching purpura of Loewenthal, eczematid-like purpura of Doucas and Kapetanakis, pigmented purpuric lichenoid dermatosis of Gougerot and Blum, lichen aureus, purpura annularis telangiectoides, purpura annularis telangiectodes, purpura simplex, Majocchi disease

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Contributor Information and Disclosures

Author

Darius Mehregan, MD, Associate Professor, Hermann Pinkus Chairman of Dermatology, Department of Dermatology, Wayne State University; Clinical Associate Professor of Pathology, University of Toledo; Dermatopathologist, Pinkus Laboratory; Consulting Staff, Department of Dermatology, J Dingell Veterans Affairs Medical Center
Darius Mehregan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, International Society of Dermatology, International Society of Dermatopathology, Phi Beta Kappa, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Jennifer Michelle Heyl, MD, Resident Physician, Department of Dermatology, Wayne State University School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jean-Hilaire Saurat, MD, Chair, Professor, Department of Dermatology, University of Geneva, Switzerland
Jean-Hilaire Saurat, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis  investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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