Henoch-Schonlein Purpura Treatment & Management
- Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Craig B Langman, MD more...
To date, no form of therapy has been found to shorten the duration of Henoch-Schönlein purpura (HSP) to any significant degree. Therefore, treatment remains primarily supportive in most cases. This is consonant with the understanding that HSP is a self-limited disease. The majority of patients recover quickly (ie, within several weeks) without treatment.
Management of HSP includes adequate hydration; immediate discontinuance of any exposure to antigenic stimulants (eg, drugs); and follow-up each week for the first month, every other week for the second month, and monthly thereafter until abnormal urinary findings subside.
Patients with HSP are often admitted to the hospital and monitored for abdominal and renal complications, which may be severe and may occur precipitously (eg, acute abdomen, acute scrotum, and renal failure). Hospitalization should be strongly considered for HSP patients with severe abdominal pain, significant gastrointestinal (GI) bleeding, or marked renal insufficiency.
HSP may mimic an abdominal emergency and, in its severest form, result in small-bowel infarction, perforation, or both.
In adults with HSP, permanent renal involvement is not uncommon. Hematuria at disease onset and persistence of renal manifestations during the occurrence of HSP can be significant predictors of possible development of renal sequelae. These manifestations, along with other features (eg, onset in summer, anemia at disease onset, or relapses of the disease), may predict the development of renal sequelae in most patients. All pregnant women with even mild renal symptoms at the onset of HSP should be carefully observed during and after pregnancy.
Nephropathy is treated supportively. Patients’ fluid and electrolyte balance should be monitored, their salt intake should be restricted, and antihypertensives should be prescribed when needed. Various drugs (eg, corticosteroids, azathioprine, and cyclophosphamide) and plasmapheresis have been used to prevent renal disease from progressing. The results have been inconsistent. No data from controlled studies are available.
Dietary restrictions have no clear role in the management of HSP. Activities can be performed as tolerated.
Treatment of HSP is primarily supportive and includes ensuring adequate hydration and monitoring for abdominal and renal complications. For minor complaints of arthritis, edema, fever or malaise, symptomatic treatment is advised, including use of acetaminophen, elevation of swollen extremities, eating a bland diet, and adequate hydration. All unnecessary drugs should be discontinued if a drug-related etiology is suspected.
Most patients with self-limited cases can be safely discharged home with close follow-up by the primary physician. The decision for or against hospital admission depends on the physician’s customary practice and individual preference. Admission to the hospital is recommended for control of abdominal pain or vomiting, monitoring of renal function, confirming a doubted diagnosis, and observation and monitoring. Patients with renal involvement require close attention to their fluid balance, electrolyte status, and use of antihypertensives (if indicated).
A study examining prevention and treatment of renal disease in patients with HSP revealed no significant difference in the risk of persistent kidney disease at 6 months and 12 months in children given prednisone for 14-28 days upon presentation in comparison with placebo or supportive treatment. Also, no significant difference was noted in the risk of persistent renal disease in children given cyclophosphamide compared with supportive treatment and with cyclosporin compared with methylprednisolone.
Pain control is essential for quality patient care. Analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen may reduce joint and soft tissue discomfort. Such agents are often effective and do not seem to worsen the purpura; however, they should be used cautiously in patients with renal insufficiency.
Clinicians often use corticosteroids to treat subcutaneous edema and nephritis in HSP, as well as to ameliorate associated arthralgias and symptoms associated with GI dysfunction. However, good, large, prospective studies regarding the treatment of HSP are lacking,[56, 57, 58] and the evidence does not yet support the use of steroids to prevent or treat renal disease.[59, 60] Some authors recommend steroids; others do not. Nevertheless, corticosteroids may be considered in the following situations:
Persistent nephrotic syndrome
Crescents in more than 50% of glomeruli
Severe abdominal pain
Substantial GI hemorrhage
Severe soft tissue edema
Severe scrotal edema
Neurologic system involvement
Prednisone in a dosage of 1 mg/kg/day for 2 weeks and then tapered over 2 more weeks may shorten the duration of abdominal pain and joint symptoms, but this benefit must be weighed against the potential adverse effects of steroids.[61, 62]
A review of randomized clinical trials for any intervention used to improve renal disease in children with HSP noted that data were very limited except for short-term prednisone; moreover, prednisone had no benefit in preventing serious long-term renal disease.
The long-term prognosis of HSP directly depends on the severity of renal involvement. Patients with HSP-related renal dysfunction may benefit from therapy. However, prophylaxis of renal complications in HSP, though interesting, is not currently recommended. Treatment of overt HSP includes methylprednisolone pulse therapy and prednisone and other immunosuppressive medications. If prednisone is used, a regimen consisting of 1-2 mg/kg/day PO for 7 days is recommended. Antihypertensives may be indicated with renal involvement.
Faedda reported favorable results from the following protocols in patients with severe HSP :
Induction with 250-750 mg of intravenous (IV) methylprednisolone daily for 3-7 days plus cyclophosphamide 100-200 mg/d administered orally (PO)
Maintenance with prednisone 100-200 mg PO every other day plus cyclophosphamide 100-200 mg/d PO 30-75 days
Tapering of prednisone by approximately 25 mg/month (with the cyclophosphamide dose remaining constant)
Discontinuance of treatment after at least 6 months by abruptly discontinuing cyclophosphamide and tapering prednisone completely
Other treatment regimens have included IV or oral steroids with or without any of the following:
High-dose IV immunoglobulin G (IVIg)
Of these, only cyclophosphamide has been shown to be effective in a randomized controlled trial. Although some studies have reported success, cyclosporine does not have sufficient clinical data to establish its utility in this setting.
Azathioprine, mycophenolate mofetil, and urokinase must be tested before their use is consistently advocated. Guidelines for prescribing azathioprine in dermatology have been established. No convincing studies have yet been conducted regarding the use of IVIg, factor XIII administration, antioxidant vitamin E, and fish oil to treat HSP.
A randomized clinical trial of cyclosporine with methylprednisolone pulses in HSP with nephritis found that cyclosporine was superior and had many fewer complications. A study of 12 patients with severe HSP nephritis indicated that patients did well with methylprednisolone at 30 mg/kg/day for 3 days followed by oral corticosteroids at 2 mg/kg/day for 2 months, cyclophosphamide at 2 mg/kg/day for 2 months, and dipyridamole at 5 mg/kg/day for 6 months.
Some have noted that parvovirus B19–associated HSP must be recognized in adults because the treatment of choice is IV gamma globulin combined with anti–tumor necrosis factor (TNF)-α therapy. In contrast, immunosuppressive therapy may lead to a persistent or worsening disease course in these patients.
Massive GI hemorrhage in isolated intestinal HSP that is responsive to IVIg infusion has been reported. IVIg was used in a complex case of HSP with brain hemorrhage, but more work must be done to validate the use of this treatment.
Dapsone has been used to treat associated purpuras and arthralgias. Iqbal and Evans found it to be effective for HSP.
Rituximab has been noted to be a successful treatment for severe refractory chronic HSP.
Factor VIII concentrate has been used to relieve abdominal pain when corticosteroids are contraindicated. Recombinant factor VIIa has been used with very pronounced factor XIII deficiency and compartment syndrome.
Treatment of complicated HSP with mycophenolate mofetil has been reported in a series of patients.
Plasmapheresis may be effective in delaying the progression of kidney disease. A case series demonstrated good outcomes in adults with severe HSP who were treated with plasma exchange in addition to steroids. In an uncontrolled study, Shenoy et al reported that children with severe HSP and IgA nephropathy recover well if treated with plasmapheresis alone, without the need for immunosuppressive therapy. Plasmapheresis has been useful in treating rapidly progressive HSP nephritis.
Surgery may be undertaken to treat severe bowel ischemia. Kidney transplantation may be indicated in patients with severe renal disease that is resistant to medical therapy. Successful treatment of progressive HSP nephritis with tonsillectomy and corticosteroid pulse therapy has been reported.
Because HSP is a multisystem disease, consultations with the following specialists can be helpful in diagnosis and treatment:
Nephrologist (particularly for assistance in determining if dialysis is indicated)
Dermatopathologist  (the utility of the consultation is limited to untypical or incomplete manifestations of HSP to buttress positive vascular IgA immunohistochemical evidence of the deposits)
Consultation is recommended for patients with renal involvement before discharge from the emergency department and for all patients who appear acutely ill.
In all patients, urinalysis and blood pressure monitoring to evaluate for renal involvement should be continued for up to 6 months after presentation, even if initial urinalysis results were normal. Once the initial course of prednisone is administered, additional prednisone appears to have no role.
When terminal renal failure develops, long-term hemodialysis should be instituted until a kidney is available for transplantation. Mesangial deposits of IgA are common in the graft, but they rarely lead to clinical manifestations of recurrent glomerulonephritis.
Children who have demonstrated renal manifestations in the acute phase and continue to have hematuria or proteinuria should be examined every 3-6 months because renal failure or hypertension can develop up to 10 years after disease onset.
NSAIDs may be administered to address joint problems. Because of the risk of Reye syndrome, the use of NSAIDs should be discussed with the patient’s physician.
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