BAN XUT HUYT BATEMAN

I. Definition:
Batemans purpura refers to flat, irregular, purple lesions that appear on your
skin as you get older. These lesions usually occur on the back of the hands and
the forearms. The skin appears thin and wrinkly, almost flimsy looking. They
are common, but not dangerous.

II. Cause:

Mostly seen on sun-damaged skin of people over fifty.

Batemans purpura is due to the weakened state of blood vessel walls.
Over many years, sunlight damages the skin and underlying blood
vessels, making the walls very fragile. With slight trauma (brushing
against something) the walls break and the blood leaks into the
surrounding skin.
Alcohol, aspirin, and prednisone can contribute to the formation of
Batemans purpura. Alcohol and aspirin thin the blood, therefore making
it easier to leak into the skin. Prednisone causes the blood vessel walls to
become very fragile.

III. Treatment:

Cosmetics can be used to camouflage the lesions. Dermablend cosmetics

are recommended for dermatologic conditions, such as Batemans
purpura. Dermablend can be bought at Department stores. Covermark
Cosmetics are also excellent at covering this condition.
Vitamin K cream applied to the skin daily has been shown to improve
this condition.
Daily application of alpha hydroxyacid lotions to the skin have been
shown to increase skin thickness up to 15% in patients with sun damaged
thin skin. This occurs through the stimulation of collagen production, the
skins natural support protein.

NTRODUCTION
Background
Actinic purpura is a benign clinical entity resulting from sun-induced damage to the
connective tissue of the dermis. Actinic purpura is characterized by ecchymoses on the
extensor surfaces of the forearms and the dorsa of the hands that usually last 1-3 weeks.
Bateman1 first described the condition in 1818 when he noted dark purple blotches and
determined that they were due to the extravasation of blood into the dermal tissue. Hence,
it is sometimes called Bateman purpura.
It is common in elderly individuals and usually occurs after unrecognized minor trauma
to the respective areas.
Clinical aspects of dermatoporosis include morphological markers of fragility, such as
senile purpura, stellate pseudoscars, and skin atrophy.2 The concept of the syndrome
term dermatoporosis has been used to compare it to osteoporosis, implying both should
be prevented and treated to avoid complications.

Pathophysiology
The purple macules and patches of this condition occur because red blood cells leak into
the dermal tissue. This extravasation is secondary to the fragility of the blood vessel walls
caused by ultraviolet radiationinduced dermal tissue atrophy. This atrophy renders the
skin and microvasculature more susceptible to the effects of minor trauma and shearing
forces. The insult to the skin is typically so minor that isolating it as a cause of the
ecchymoses can be difficult.

Notably, no inflammatory component is found in the dermal tissue. The absence of a

phagocytic response to the extravascular blood has been postulated to be responsible for
delaying resorption for as long as 3 weeks.
Actinic purpura may be, along with osteoporosis, a sign of collagen loss in skin and
bone.3 This causal loss of skin collagen has been confirmed when collagen was expressed
absolutely, instead of as a percentage or ratio. That is, women have less collagen than
men and it decreases by 1% a year in exposed and unexposed skin. These changes in skin
collagen may correspond to changes in bone density. The hypothesis is that the changes
in skin collagen also occur in bone collagen, leading to the associated changes in bone
density.

Frequency
United States
Actinic purpura is an extremely common finding in elderly individuals, occurring in
approximately 11.9% of those older than 50 years. Its prevalence markedly increases with
years of exposure to the sun.
International
Data are not available.

Mortality/Morbidity
The ecchymoses may be cosmetically distressing and may leave dyspigmentation or
scarring, but the lesions are not associated with any serious complications.

Race
The effects of chronic sun exposure with the resultant ultraviolet radiationinduced skin
changes occur more often and are more pronounced in fair-skinned individuals than in
others.

Sex
Both sexes are equally affected.

Age
Actinic purpura occurs almost exclusively in the elderly population, though it may
sporadically occur in younger people. The incidence varies with respect to age.
Approximately 2% of those aged 60-70 years and as many as 25% of those aged 90-100
years can have the purpuric lesions.

CLINICAL
History

Patients may report the appearance of purple blotches or bruises on their

forearms, hands, face, or neck.
The macules are not associated with pain or pruritus.
Constitutional symptoms (eg, fever, malaise, weight loss) are absent.
The patient may report a history of the lesions resolving and then subsequently
reappearing. Residual brown pigmentation may appear after the purpuric macules
resolve.
Individual lesions usually last 1-3 weeks, and they do not undergo the color
changes that occur with other types of purpuric lesions.
Patients are typically unaware of any external trauma that may have been
responsible for the ecchymoses.
Individuals may report a history of chronic sun exposure to skin sites where
lesions are present.
Individuals with actinic purpura are often taking blood-thinning medications such
as aspirin or warfarin, which can aggravate the condition.

Physical

Purpuric patches and macules larger than 3 mm in diameter are usually present on
the extensor surfaces of the forearms and on the dorsa of the hands; the lesions do
not extend onto the fingers.
o Ecchymoses may also be found on the neck and face.
o Macules and patches are dark purple and irregularly shaped.
o A sharp margin is seen between the borders of the lesions and the
surrounding skin.
Some macules are more deeply colored than others because the duration of the
lesions varies. The color changes that are typically associated with purpura or
ecchymoses due to other causes do not occur, although residual brown
pigmentation may persist.
Lesions of actinic purpura occur in areas of atrophic and inelastic photodamaged
skin.
o Other signs of dermatoheliosis often present include leathered wrinkling,
stellate pseudoscars, and a sallow yellow hue to the skin.
o Lentigines and scars may be present.
o The skin may appear darker secondary to hyperpigmentation due to
hemosiderosis.

Causes

Chronic sun exposure leads to skin changes that predispose patients to actinic
purpura.

Because of the ultraviolet-induced atrophy, the connective tissue of the dermis is

no longer able to adequately support the microvasculature.
As a result, even minor trauma can tear the blood vessels, leading to the
extravasation of blood.

DIFFERENTIALS
Amyloidosis, Primary Systemic
Pseudoxanthoma Elasticum

Other Problems to be Considered

Purpura induced by topical or systemic glucocorticoid use
Hemophilia
Anticoagulant use (eg, aspirin, warfarin)
Vitamin K deficiency
Disseminated intravascular coagulation
Idiopathic thrombocytopenic purpura
Coumarin necrosis
Hepatic insufficiency with poor procoagulant synthesis
Psychogenic purpura
Physical abuse
Other causes of cutaneous pseudovasculitis
Cutaneous pseudovasculitis is a heterogeneous collection of disorders that manifest as
purpura.4 They may be caused by vessel wall deposition of metabolic substances
(amyloid, calcium), nutritional deficiencies (scurvy), nonvasculitic inflammatory purpura
(pigmented purpuric dermatitis, arthropod reactions, viral and drug reactions),
degeneration of the vessel wall and supporting stroma (senile/solar purpura), direct vessel
wall invasion of infective organisms, coagulation-fibrinolytic disorders (eg,
thrombocytopenia), and vessel wall trauma.

WORKUP
Lab Studies

The diagnosis of actinic purpura is usually obvious at clinical examination.

Laboratory investigation is not required unless the diagnosis is not readily
apparent.
Findings of the following tests are in the reference ranges:
o Complete blood cell count
o Coagulation studies
o Platelet count determination
o Liver function studies
o Urinalysis

Stool guaiac test

Histologic Findings
Biopsy reveals a thinned epidermis with many abnormal keratinocytes in a disorderly
pattern. The upper dermis contains extravasated red blood cells and hemosiderin without
evidence of inflammatory cells. At histologic evaluation, solar elastosis can be
appreciated in the surrounding skin as faintly blue homogenized elastotic material lying
just below a layer of normal connective tissue at the base of the epidermis. The amount of
abnormal elastic fibers is markedly increased, and the amount of collagen is decreased.

TREATMENT
Medical Care

Actinic purpura does not require extensive medical care.

o To prevent further ultraviolet-induced damage to the skin, sunscreens that
provide both UV-A and UV-B protection should be applied daily,
especially to areas affected by the purpuric lesions.
o Patients should also use barrier protection (eg, clothing).
o Inform patients that sunscreens help prevent but do not reverse the
photodamage.
Tretinoin has been observed to reverse many changes that occur with
photodamage.
o The use of tretinoin may be beneficial in actinic purpura because
photodamage is ultimately responsible for this disorder.
o Tretinoin increases the amount of dermal collagen and decreases the
amount of abnormal elastin when applied topically. However, to the
authors' knowledge, no results demonstrate that actinic purpura lesions
improve with the topical application of tretinoin.

Activity

Advise patients with actinic purpura to limit their sun exposure by applying
sunscreen daily or by avoiding sun exposure altogether.
Instruct patients to minimize any trauma to the skin where the purpuric lesions are
present.

FOLLOW-UP
In/Out Patient Meds

Recommend the use of sunscreens that provide both UV-A and UV-B protection.

Deterrence/Prevention

Actinic purpura can be prevented by using lifelong sun protection.

Advise patients to adhere to the following precautions, starting at the earliest
possible age.
o Avoid sun exposure when the most damaging rays are present (ie, from 10
am to 3 pm).
o Wear clothing at all times while outdoors to serve as barrier protection
from the sun's UV rays.
o Apply sunscreens that protect against UV-A and UV-B radiation daily,
especially to areas of the skin that are not covered by barrier protection.

Complications

Actinic purpura is a benign condition and does not have serious complications.
The lesions may be emotionally distressing to patients because of the cosmetic
disfigurement of the skin.

Prognosis

Individual lesions of actinic purpura generally resolve within 1-3 weeks.

Residual hemosiderosis may occur. Purpuric lesions usually continue to occur
during the individual's life.

Patient Education

Reassure the patient that this condition is benign.

Emphasize the absolute necessity of using sunscreen and barrier protection to
prevent further photodamage.
Inform patients that sunscreens do not reverse photodamage.
Instruct patients to minimize any trauma to the skin where the purpuric lesions are
present.

MISCELLANEOUS
Medical/Legal Pitfalls

The clinical sign of purpura is not necessarily benign.

o Although actinic purpura does not have serious sequelae, other causes of
purpura can be serious.
o An incorrect diagnosis as to the etiology of purpuric lesions can be
medically and legally disastrous.