Differential Diagnosis for Skin Conditions

Differential Diagnosis
1: Senile Purpura
Characteristics using clinical terminologies
Senile Purpura denotes RBC (red blood cell) extravasation into the mucous membrane or skin. Thus, purpuric lesions don’t blanch upon pressing with a finger or glass slide (diascopy). The condition has a broad differential diagnosis which may be easily narrowed down through classification on the basis of morphology, and other lab and clinical findings (Soutor & Hordinsky, 2013). Associated clinical terminologies and differential diagnosis include:
Petechiae: These are flat lesions, not more than 4mm-dimension macules, usually bright red at first. They subsequently fade and acquire a rusty color.
Ecchymosis: Also flat lesions, >5mm patches or macules, usually purple or red at first. They subsequently fade and acquire a green, yellow, or brown color.
Palpable purpura: Oval or round, elevated, occasionally hardly noticeable, purple or red plaques or papules.
Retiform purpura: Branching or stellate lesions having geometric or angular borders, occurring both as non-palpable patches and clear plaques (Soutor & Hordinsky, 2013).
Explore different conditions that could be the cause of the skin abnormality
Senile Purpura (blood spots, purpura senilis, and skin hemorrhages): This condition widely occurs among aged individuals with a tendency of developing bruises, particularly on their legs and forearms. The bruises aren’t caused by mineral and vitamins deficiencies or bleeding disorders. Aged individuals’ skin and skin blood vessels become fragile and thin, causing bruises which initially have a purplish red color. Large purpura are termed ecchymoses while extremely small purpura spots are termed petechiae (PHC, 2018).
Causes:
· Natural weakening of connective tissues and thinning of the skin with age
· Overuse of steroids, aspirin and other blood thinners
· Diabetes or vascular ailments
· Thrombocytopenic purpura emerges because of meningococcemia and similar infections and medications preventing formation of platelets or disturbing platelet functioning
Associated diseases (Differential Diagnosis)
Bacterial infection
Meningococcal septicaemia, diphtheria and streptococcal septicaemia are examples of purpuric rash-causing bacterial infections. Further, a number of serious viral infections (e.g., Ebola viral fever, Lassa fever, Rift Valley viral fever, chickenpox, smallpox, measles and parvovirus B19) result in purpuric rashes (Imm, 2015).
Allergic vasculitic purpura
HSP (Henoch-Schönlein purpura) represents one such commonly occurring condition caused by blood vessel wall infiltration and swelling as the anaphylactic response to various chemical and physical stimuli (such as infections). ?-haemolytic streptococcal infection-triggered upper respiratory tract infections typically precede it. It may occur as an epidemic among children, characterized by a fever and a slightly-raised purpuric rash (Saulsbury, 2010), normally affecting the buttocks and the front of the legs. Acute arthritis, nephritis with proteinuria and gastrointestinal pain may occur in association. The rash can continue forming over many weeks, with major, severe complications including bleeding in the central nervous system, acute injury of the kidney or acute intussusception. It is generally self-limiting though potentially responsive to steroids. Cochrane review failed to produce any evidence of benefits of short prednisolone courses in acute kidney illness prevention in Henoch-Schönlein purpura (Hahn, Hodson, Willis, et al., 2015)
Disseminated intravascular coagulation (DIC)
DIC is marked by major ecchymosis with an erythematous halo and irregular, sharp, purple-colored boundaries. The condition may aggravate and give rise to blue-black gangrene ando haemorrhagic bullae, appearing as symmetrical multiple lesions involving pressure areas, distal extremities, and the lips, nose, trunk and ears (Imm, 2015).
Strong steroids
Continued strong steroid consumption may result in widespread bruising and purpura, commonly on the arms’, thighs’, and hands’ extensor surfaces, caused by skin blood vessel-supporting collagen fibers’ atrophy. This appears similar to senile purpura (Imm, 2015).
Blood transfusions
Serious thrombocytopenia between 5 and 12 days of receiving any platelet-containing blood product seldom occurs and is normally limited only to multiparous females (Shtalrid, Shvidel, Vorst, et al, 2006). This occurs because of the development of a particular platelet antigen’s antibody usually lacking in the patient. Though the normal recovery period from this illness is 1-3 weeks, it may prove lethal and require treatment using intravenous immunoglobulins or plasmapheresis.
Pigmented purpuric dermatoses
These represent a disease group whose characteristic feature is erythrocyte extravasation, especially in the lower legs, linked to haemosiderin deposition (Imm, 2015).
Amyloid
Secondary as well as primary amyloid may lead to ‘pinch’ purpura, called so because it usually appears on the individual’s cheeks (Crookston et al., 2010)
Factitial purpura
This might be considered in case of episodes of unexplainable bruising or bleeding. They can represent acute psychiatric or emotional disturbance or even signify abuse (Yamada, Sakurai, Shibata, et al, 2009).
Palpable purpura:
1. Collagen Vascular ailments
· Sjogren’s syndrome
· Rheumatoid arthritis
· SLE (Systemic Lupus Erythematosus) (PHC, 2018)
2. Internal Malignancies
· Leukemia
· Multiple Myeloma
· Lymphoma
3. Leukocytoclastic Vasculitis
· Purpura stimulating factors such as infections, medications and blood abnormalities
· Vasculitic brain, lungs, kidneys, gastrointestinal tract, and liver injuries
· Necrotizing small-vessel vasculitis (PHC, 2018)
4. Other
· Polyarteritis nodosa
· Vasculitis disorders
· Granulomatous vasculitis
· Henoch-Schonlein syndrome (PHC, 2018)
Non-palpable Purpura
1. Coagulopathies
· Drug induced thrombocytopenia
· Disseminated intravascular coagulation
· Idiopathic thrombocytopenic purpura
· Viral diseases and Bacteremia
· Thrombocytopenic purpura (PHC, 2018)
2. Others
· Chronic stasis
· Scurvy
· Trauma
· Systemic diseases
· TORCH infection
· Old age
· Actinic changes
· Anticoagulant therapy (PHC, 2018)

Examination
Prioritizing examination over history is seemingly strange, though logical. In fact, patients will probably commence consultation through presenting their rash(es) for inspection. Thus, lesions’ nature (size, associated blisters, presence or absence of blood, exudate or pus, confluence, etc.) and location ought to be noted. Trauma tends to give rise to localized lesions while venous hypertension-triggered purpura will be distributed in the lower leg region. Patient age is also important. Myeloproliferative disorders and leukemia develop among individuals of all ages; HSP largely develops among children; and senile purpura only occurs among the aged.
Diagnosis
· Normal hemostasis
· Lab tests
· Positive capillary fragility test
· Normal platelet count (PHC, 2018)
Diagnostic criteria
· Common among aged men and women (>60 years of age)
· Positive beam arm test
· Normal platelet count
· Normal hemostasis
· Skin purpura of roughly 1-4 cm diameter, mostly on exposed areas like face, neck, hands, underarms, and legs.
· Affected skin atrophy (PHC, 2018)

Bibliography
Crookston K et al (2010). Acquired bleeding disorders. Amyloidosis, PathologyOutlines.com.
Hahn D, Hodson EM, Willis NS, et al, (2015). Interventions for preventing and treating kidney disease in Henoch-Schonlein Purpura (HSP). Cochrane Database Syst Rev. Doi: 10.1002/14651858.CD005128.pub3.
Imm, N. (2015). Purpuric Rashes. Patient Platform Limited.
PHC. (2018). Senile Purpura. Prime Health Channel.
Saulsbury, FT (2010). Henoch-Schonlein purpura. Curr Opin Rheumatol. 598-602
Shtalrid M, Shvidel L, Vorst E, et al, (2006). Post-transfusion purpura: a challenging diagnosis. Isr Med Assoc J. 672-4.
Soutor, C., & Hordinsky, M. (2013). Clinical Dermatology. New York: McGraw Hill Professional.
Yamada K, Sakurai Y, Shibata M, et al, (2009). Factitious purpura in a 10-year-old girl. Pediatr Dermatol. 597-600.