Introduction

Understanding purpura

Purpura is a term used where the skin has a purple or red rash due to bleeding underneath, which occurs in different conditions.¹

When purpura spots are <1cm in diameter they are called petechiae or petechial haemorrhages. Larger and deeper purpura are called ecchymoses or bruising. Purpura can manifest as either thrombocytopenic purpuras, which have low platelet counts, or non-thrombocytopenic purpuras, which have normal platelet counts. Platelets play a crucial role in the clotting process and in preserving the integrity of the capillary lining. Purpura often denotes a platelet system issue, whereas haemorrhagic disorders, such as haemophilia, result from a lack of clotting factors. However, clotting factor insufficiency needs to be taken into account.¹¹

Types of conditions with purpura

There are many types of conditions with purpura, such as:^1,5

• Idiopathic thrombocytopenic purpura
• Henoch-Schönlein purpura
• Thrombotic thrombocytopenic purpura (TTP)
• Immune thrombocytopenic purpura (ITP)
• Actinic purpura
• Purpura Fulminans – neonatal, idiopathic, acute infectious

A brief overview of types of conditions with purpura

• Idiopathic thrombocytopenic purpura – low platelet count (thrombocytopenia) with no known cause (idiopathic)⁷
• Henoch-Schönlein purpura – also known as IgA vasculitis. Involves small vessels of kidneys, skin, gastrointestinal tract, and joints⁸
• Thrombotic thrombocytopenia purpura – life-threatening and rare thrombotic microangiopathy, a group of disorders which are characterised by the following: severe thrombocytopenia (platelet count is too low), microangiopathic haemolytic anaemia (damage to the red blood cells), and organ ischemia (inadequate blood supply). TTP is linked to a deficiency of the protein ADAMTS13²
• Immune thrombocytopenia purpura – an autoimmune disease characterised by purpura, low platelet count, and haemorrhagic (bleeding) episodes which are caused by antiplatelet autoantibodies, your own body creates antibodies that attack your platelets³
• Actinic purpura – known as senile purpura, solar purpura, Bateman purpura, or Bateman disease. It is a disorder of the connective tissue of the skin due to being exposed to the sun for prolonged periods⁴
• Purpura Fulminans – purpuric rash which can lead to purpuric lesions and skin necrosis, due to coagulation (clotting) of the microvasculature, which consists of the arterioles, capillaries and venules. It is a dermatological emergency and requires immediate attention. Has 3 types - neonatal (hereditary deficiency of 3 anticoagulants), idiopathic (post-infectious autoimmune disorder), and acute infectious (most common type). In the most severely septic individuals, it presents as a cutaneous (skin) finding and also occurs as necrotising fasciitis (flesh-eating disease) with a preference for specific infectious pathogens⁵

Purpura prevention

Purpura is not a condition in itself but a symptom of different health conditions, so it is not possible to prevent purpura. Certain preventative measures can be taken against different types of purpura.⁶ Where possible, if certain methods of prevention can be taken without affecting your health then it may be a good idea to do so. It would be best to speak to your doctor to see what is best for you.

Understanding risk factors

Risk factors

Certain factors may increase the risk of developing purpura, such as:⁶

• Age – elderly people have more fragile blood vessels, which can lead to higher rates of purpura (e.g. actinic purpura)
• Sex – people assigned female at birth (PAFAB) have a higher incidence rate of immune-related purpura
• Family history – having a family history of purpura can be associated with an increased risk
• Medication – certain medications, such as steroids and blood thinners, can affect blood vessels or platelets, which can increase the risk
• Health condition – autoimmune conditions, blood clotting disorders, and viral infections are associated with developing purpura

Strategies for purpura prevention

Before using any strategies to prevent purpura, it may be best to speak to your doctor about what prevention methods are suitable for you and if they may affect your health.

Dietary measures

Following a Mediterranean diet has been shown to decrease the risk of developing thrombocytopenia and maintaining platelet counts within the normal range. This would include a Mediterranean diet enriched variety of foods, reducing and replacing certain foods such as:⁹

• Fruits
• Nuts
• Pules
• Fish
• Using extra virgin olive oil as the main culinary fat
• Reducing consumption of sugary drinks, pastries, sweets, and bakery goods, and spreading fat
• Replacing red / processed meat with poultry

The PDSA (Platelet Disorder Support Association) suggests eating more of:¹⁰

• Fresh whole foods – vegetables, nuts, fruits, legumes, whole grains
• Healthy fats – olive oil or canola oil
• Leafy greens – spinach, collard greens, and kale are sources of vitamin K, minerals, and calcium all of which promote clottingVegetables

Lifestyle modifications

Lifestyle tips from the PDSA:¹⁰

• Reduce stress – stress has been shown to aggravate many diseases. Managing and reducing stress will be better for your life
• Maintain a positive mindset – according to some studies, thinking more positively can improve your chances of feeling better
• Exercise – find an exercise that fits you and your health
• Sleep well – sleeping too little or too much can aggravate health problems according to research
• Eat well – eat when your body feels hungry

Medication management

The treatment of purpura is dependent on the cause. For thrombocytopenic purpura treatment includes:⁶

• Intravenous immunoglobulin (IVIG) – IVIG contains antibodies that help raise the levels of platelets
• Thrombopoietin receptor agonists – medications that stimulate the production of platelets. Often used when other treatments have been ineffective
• Corticosteroids – anti-inflammatory medications that suppress overactive immune response, resulting in reduced destruction of platelets
• Splenectomy (spleen removal) – surgical spleen removal is usually considered in severe cases where the spleen has a role in platelet destruction

Nonthrombocytopenic purpura has no specific treatment as it can sometimes resolve on its own with no need for medication. If an underlying condition is causing it then treatment may include:⁶

• Stopping or adjusting medication doses that may be the cause
• Antibiotics or antivirals for infections
• OTC (over-the-counter) anti-inflammatory and pain relief medication
• Immunosuppressive drugs to treat any autoimmune conditions

FAQs

What triggers purpura?

Purpura occurs when bleeding happens underneath the skin. Purpura itself is not a disease but it is a symptom of different diseases.¹

What does purpura look like?

Purpura can appear as small spots (petechiae) or as larger patches (bruising)¹¹, and it will appear purple or red.¹

Can ageing cause purpura?

Age is a risk factor in developing purpura.⁶

Can anything help purpura?

Certain medications can help manage purpura depending on the severity and the underlying condition. Actinic purpura can resolve by itself and does not require medication.⁶

Summary

The presentation of purpura as red or purple skin spots is a direct result of bleeding beneath the skin, ranging in size from pinpoint petechiae to more extensive ecchymoses. This symptomatology indicates potential abnormalities in platelet functionality or blood clotting, seen in different conditions such as thrombotic thrombocytopenic purpura and actinic purpura. These conditions range from autoimmune diseases to connective tissue disorders, each with distinct mechanisms and implications for health.

Individuals at increased risk include the elderly, due to more fragile blood vessels, PAFAB who may experience immune-related purpura more frequently, and those with a family history or on certain medications that compromise blood vessel integrity or platelet function. Additional risk comes from underlying health issues like clotting disorders.

Preventive actions are customised for each person's unique risks and circumstances. Making dietary changes, including incorporating the Mediterranean diet into the lifestyle, can improve the health of platelets and lower the risk of thrombocytopenia. Reducing stress, adopting an optimistic outlook on life, engaging in proper exercise, and getting enough sleep are among the suggested lifestyle changes that can improve general well-being and possibly lower the incidence of purpura.

Treatment is dependent on the underlying condition as there is no specific treatment for purpura. Depending on the condition medication may be used, such as corticosteroids or immunosuppressants.

Any treatments, prevention, and management of the underlying conditions causing purpura are best discussed with a doctor who can best advise you on what is beneficial for you.