Skin Disorders in Older Adults: Vascular, Lymphatic, and Purpuric Dermatitides, Part 1

All elements of the skin are affected by age. In this 2-part article, I will discuss how the blood vessels, the lymphatics, and the ground substance—which surrounds these vessels—respond to age, and I will show how the aging elements of the vasculature can engender a variety of pathological cutaneous conditions.

Here I focus on solar purpura, benign pigmented purpura, cherry angiomas, venous lakes, varicose veins, and spider telangiectasia. In Part 2, I will discuss elephantiasis nostrum verrucosa, lipodermatosclerosis, atrophie blanche, pyogenic granuloma, giant cell arteritis, and leukocytoclastic vasculitis.

SOLAR PURPURA

Figure 1 – Solar purpura on this elderly woman’s forearm appears in various stages of resolution. As the patches and macules resolve, they fade to lighter shades of purple, rather than the brown color characteristic of other ecchymoses.

Solar purpura is common in older adults, particularly elderly white men and women. It results from sun-induced damage to the connective tissue of the dermis and is also referred to as actinic, or senile, purpura.

The purpuric lesions are usually found on the extensor surfaces of the forearms and the dorsa of the hands at sites of minor trauma; the lesions do not extend onto the fingers. Solar purpura can also occur on the neck.

Clinically, solar purpura manifests as patches and macules that are usually purple and irregularly shaped and range in size from 3 mm to 5 cm (Figure 1). The lesions commonly occur on a background of dermatoheliosis, which manifests as lichenification, stellate white pseudoscars, and sallow skin color.

Depending on the duration of the lesion, some are more deeply purple than others. Unlike other ecchymoses, which evolve into brown patches, solar purpura tends to fade to fainter shades of purple, although residual brown pigmentation may persist. The lesions typically resolve over 1 to 3 weeks.

BENIGN PIGMENTED PURPURA

The pigmented purpuric dermatoses include the following conditions:
• Eczematid-like purpura of Doucas and Kapetanakis (purpura with scale on the surface) (Figure 2).
• Purpura annularis telangiectodes (Majocchi disease, or purpura with associated telangiectasia) (Figure 3).
• Lichen aureus (golden purpura) (Figure 4).
• Schamberg disease (progressive pigmented dermatosis) (Figure 5).
• Itching purpura of Loewenthal.
• Pigmented purpuric lichenoid dermatosis of Gougerot and Blum.

Many consider itching purpura and eczematid-like purpura to be variants of Schamberg disease.

Figure 2 – Eczematid-like purpura of Doucas and Kapetanakis, seen here on an elderly man’s legs, can be distinguished from other benign pigmented purpuric dermatoses by the presence of scale.	Figure 3 – The rash on this woman's arm is typical of Majocchi disease (purpura annularis telangiectodes).
Figure 4 – Lichen aureus (golden purpura) is one of the benign pigmented purpuric dermatoses.	Figure 5 – Petechiae on this elderly man’s legs are characteristic of Schamberg disease, which usually affects the lower extremities.

These dermatoses manifest with petechiae and purpura; they usually occur on the legs, but any area of the body can be affected. Although they are cosmetically unattractive, they are not associated with serious sequelae. Sometimes pigmented purpura is pruritic.

Schamberg disease can occur at any age. Itching purpura and the dermatosis of Gougerot and Blum mainly affect middle-aged men. Lichen aureus and Majocchi disease are predominantly diseases of children and young adults.

The cause of pigmented purpura is unclear, and the lesions can resolve spontaneously. Treatments include topical corticosteroids and topical vitamin C.

An important consideration when you assess a patient with widespread pigmented purpura is that such a presentation can in fact be cutaneous T-cell lymphoma.¹ Extensive pigmented purpura should be biopsied and the specimen sent to a dermatopathologist for evaluation.