Treating A Patient With Annular Lesions On The Lower Extremities

Tracey Vlahovic, DPM, FAPWCA

What You Should Know About Cutaneous LCV And PCSVV

This patient has cutaneous leukocytoclastic vasculitis. Biopsy results showed neutrophilic perivascular infiltrate and extravasation of red blood cells. The LCV can be associated with drug reactions, infections, malignancies and systemic inflammatory conditions. However, LCV can present idiopathically with no correlation to any systemic disorder.1 This presentation is generally termed as primary cutaneous small vessel vasculitis (PCSVV) and has no extracutaneous involvement.2    The most common cutaneous presentation begins as a crop of palpable purpura or non-blanchable lesions.3 It primarily occurs on the “dependent” areas of the body such as feet, legs and buttocks. The initial crop of lesions may resolve in a month with residual pigmentation. However, while present on the skin, they may cause pruritus, burning and stinging. The lesions can be exacerbated by sun exposure, continued pressure on the affected areas and exercise.4 Otherwise, the prognosis is good since primary cutaneous small vessel vasculitis generally is a single episode.    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.

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