Wound Sleuth - Wounds Canada
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Wound Sleuth
By R. Gary Sibbald, MD and Pat Coutts, RN
Small Red Spots on the Lower Legs
History: A 43-year-old airline blood vessels have also been
What is it, and what is the
company receptionist presented linked to a potential cell-medi-
with itchy legs and a bright red cause? ated immune response. The
speckled cayenne-pepper-like Diagnosis and potential etiolo- ingestion of associated drugs was
appearance to the lower legs gies: These are benign pigmentary detected in 14% of a large pub-
(see Figures 1 & 2). She has purpura due to leaky red blood lished survey of 174 cases.1 The
seasonal allergies and previ- vessels from the small capillaries authors identified agents such
ous reactions to ibuprofen and on the surface of the skin. The as acetaminophen, ASA, NSAIDs,
shellfish. Our patient is on no leakiness can be due to venous furosemide, bromine-containing
systemic medication. disease, especially with swelling drugs, carbamazepine, thiamine
Examination: Clusters of at the end of the day. Such leaky or sildenafil.
small bright red purpuric lesions
were visible on the lower legs
below the knees. Mixed with
the lesions were resolving
brown-yellow spots. None of
the lesions were palpable to the
fingertips. There was evidence
of venous varicosities and a
palpable dorsalis pedis pulse.
Investigations: Her hemoglo-
bin was normal at 135 g/L (nor-
mal 110–147 g/L) with normal
renal and liver function tests.
The HbA1c was 6.1%, indicating
prediabetes with the lab value of
≥ 6.5% as diagnostic of diabetes.
The immunoglobulin electro-
phoresis was normal, and ANA
Figures 1 & 2: Clusters of small bright red purpuric lesions visible on the
(antinuclear factor) was negative.
lower legs below the knees
Volume 18, Number 2 · Summer 2020 Wound Care Canada 21
Other uncommon potential structure around the ankles, plus Tip
associations are infections atrophie blanche (white atrophy
and, rarely, in long-term cases Topical moisturizers or
areas and non-palpable purpura).
dermatological preparations
(years), cutaneous T cell lymph-
can be kept in the refrigerator
oma, macroglobulinemia and
Treatment to relieve itch with a cool sen-
rheumatoid arthritis. Most cases
Treatment may include the use sation upon application.
are idiopathic.
of oral bioflavonoids or ascorbic
Differential diagnosis: acid. If the area is itchy, topical
Pigmentary purpura can calcineurin inhibitors (prescrip- If venous disease is evident
be distinguished from vascu- tion for tacrolimus 0.1% ointment with a palpable foot pulse,
litis through touch. In vascu- or pimecrolimus cream) can be support stockings, knee high
litis, the lesions are palpable used and will not thin the skin with 8–15 mm or 15–20 mm Hg
to the fingertips. Cutaneous like topical steroids. There are may be useful. Other systemic
small vessel vasculitis (formerly newer prescription H1 antihista- alternatives include pentoxifyl-
leukocytoclastic vasculitis) may mines that would also help with line 400 mg daily, or colchicine,
involve internal organs in 50% itch and do not cause drowsiness 0.6 mg bid.
of cases—commonly joints, kid- with 24-hour coverage (bilastine
ney and liver, and less common- 20 mg or rupatadine 10 mg); or Reference
ly lungs, heart and GI tract. cetirizine (10 mg OTC and 20 mg 1. Ratnam KV, Su WP, Peters MS. Purpura
Also in the differential diag- simplex (inflammatory purpura
Rx) that can cause drowsiness in
without vasculitis): A clinicopathologic
nosis are vasculopathies with a 20% of individuals, so it should study of 174 cases. J Am Acad
net-like small-vessel prominent be taken at night. Dermatol. 1991;25(4):642–647.
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Volume 18, Number 2 · Summer 2020
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