Treating A Patient With Annular Lesions On The Lower Extremities

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Author(s): 
Tracey Vlahovic, DPM, FAPWCA

   In addition to the skin involvement, constitutional symptoms may be present but generally primary cutaneous small vessel vasculitis does not extend beyond the skin. If further extracutaneous involvement is visible, one should consider systemic and/or connective tissue disease. Even though a biopsy in this case suggested cutaneous leukocytoclastic vasculitis, primary cutaneous small vessel vasculitis is generally a diagnosis of exclusion. It is important to perform a detailed history and physical exam, and rule out various systemic and connective tissue disorders that may present similarly clinically.

A Guide To The Differential Diagnosis

Systemic lupus erythematosus and other connective tissue disorders. The annular nature of these lesions occurring in a conceivably sun exposed area (lower legs) allows for systemic lupus erythematosus as a differential diagnosis. If the classic characteristic butterfly facial rash or atrophic scarring occurs following the initial skin rash on the sun exposed areas, one should strongly consider systemic lupus erythematosus and discoid lupus erythematosus, and conduct a skin biopsy. Also complete a thorough history and physical.

   Drug reaction. Drug reactions may present with palpable purpura and target-like lesions. Fixed drug eruptions in which the skin reaction occurs in the same anatomical area that receives the drug may also cause annular pigmented lesions.

   Henoch-Schönlein purpura. Typically occurring in children and young adults, Henoch-Schönlein is characterized by palpable purpura, arthralgia and abdominal pain.5 It commonly occurs on the buttocks and the lower extremities where primary cutaneous small vessel vasculitis is generally found.

Salient Insights On Diagnostic Testing And Treatment

The skin biopsy in this case supported the clinical diagnosis and the history and physical exam helped to rule out connective tissue disease. The patient did not undergo a separate biopsy for direct immunofluorescence evaluation at this time. The patient also underwent further testing, such as complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), urinalysis, liver function tests and hepatitis serology.

   The aforementioned patient underwent treatment with systemic corticosteroids (a long prednisone taper) and is still undergoing treatment for this condition. However, if the aforementioned patient had an underlying systemic disorder or a suspected drug reaction, one would have addressed that prior to prescribing prednisone for the skin manifestation.

   Although primary cutaneous small vessel vasculitis is generally a self-limiting entity, conservative methods such as oral NSAIDs, antihistamines and leg elevation can be options. Research has also described a bland diet in assisting to decrease the development of palpable purpura.6 In addition to oral prednisone, dapsone (Aczone®, Allergan), colchicine (Colcrys®, AR Scientific) and cyclosporine have shown some success in decreasing the symptoms.6

   The primary cutaneous small vessel vasculitis may represent an evolving systemic disorder. If and when the patient’s skin symptoms clear, it is important to monitor the patient for both recurrence of the skin rash and any other clinical changes.

   Dr. Vlahovic is an Associate Professor at the Temple University School of Podiatric Medicine. She is a Fellow of the American Professional Wound Care Association and is board certified by the American Board of Podiatric Surgery.
   Dr. Vlahovic pens a bimonthly blog for Podiatry Today. For more info, visit http://www.podiatrytoday.com/blogs/tracey-vlahovic-dpm .

   Editor’s note: For a related article, see “How To Treat Granuloma Annulare” in the December 2004 issue of Podiatry Today or visit the archives at www.podiatrytoday.com .

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