Treatment of Actinic Purpura

Abstract

Mature skin is prone to bruising, resulting in a condition known as actinic purpura, characterized by unsightly ecchymosis and purple patches. Similar to other skin conditions, the incidence of actinic purpura increases with advancing age and occurs with equal frequency among men and women. The unsightly appearance of actinic purpura may be a source of emotional distress among the elderly. A new product has been formulated specifically for the treatment of actinic purpura. This product contains retinol, ahydroxy acids, arnica oil, ceramides, niacinamide, and phytonadione, which effectively treat actinic purpura by improving local circulation, thickening the skin, and repairing the skin barrier. The objective of this paper is to review the beneficial properties of these ingredients and their respective roles in the treatment of actinic purpura.

Full text

4444 JCAD journal of clinical and aesthetic dermatology June 2017 • Volume 10 • Number 6
I
Mature skin is prone to bruising,
resulting in a condition known
as actinic purpura,
characterized by unsightly
ecchymosis and purple
patches. Similar to other skin
conditions, the incidence of
actinic purpura increases with
advancing age and occurs with
equal frequency among men
and women. The unsightly
appearance of actinic purpura
may be a source of emotional
distress among the elderly. A
new product has been
formulated specically for the
treatment of actinic purpura.
This product contains retinol, α-
hydroxy acids, arnica oil,
ceramides, niacinamide, and
phytonadione, which
eectively treat actinic purpura
by improving local circulation,
thickening the skin, and
repairing the skin barrier. The
objective of this paper is to
review the benecial properties
of these ingredients and their
respective roles in the
treatment of actinic purpura.
J Clin Aesthet Dermatol.
2017;10(6):44–50.
A B S T R A C T R E V I E W
Treatment of Actinic Purpura
ROGER I. CEILLEY, MD
Dermatology PC, West Des Moines, Iowa
IN RECENT YEARS, THE
incidence of actinic purpura has
increased substantially among the
older patients in my dermatology
practice. Although not a serious
condition, its unsightly appearance is
a significant cause of anxiety and the
principle available treatment has
been reassurance that the lesions will
eventually resolve. The goal of this
paper is to briefly review actinic
purpura and describe a new product
specifically developed for the
treatment of actinic purpura and the
prevention of future lesions.
AGING SKIN AND THE AGING
POPULATION
Skin aging is a complex process
associated with cumulative DNA
damage1due to intrinsic factors, such
as the action of reactive oxygen
species,2and exogenous factors
including exposure to ultraviolet
light.3The skin becomes thinner and
less elastic (solar elastosis),4and the
barrier function of the skin decreases
due to depletion of lipids in the
stratum corneum.5This fragility
syndrome has been termed
dermatoporosis.6Changes in normal
skin physiology include increased
susceptibility to infection,
diminished superficial pain
Disclosure: The author acknowledges the editorial assistance of Dr. Carl S. Hornfeldt,
Apothekon, Inc., with funding provided by Ferndale Healthcare.
Author correspondence: Roger I. Ceilley, MD; E-mail: rceil45@gmail.com

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JCAD journal of clinical and aesthetic dermatology June 2017 • Volume 10 • Number 6
R E V I E W
perception, and decreased
immune and inflammatory
responses.7
In addition, the incidence of
skin disorders increases with
age.8,9 Among patients 65 years of
age or older in one study
(N=198), all had one or more
dermatologic conditions. These
included solar lentigines, senile
angiomas, xerosis, seborrheic
keratoses, varicose veins, and
pruritus.10 Patients 75 years of
age or older were more likely to
suffer from solar lentigines, clavi,
solar keratoses, and
onychomycosis.1 0 Unfortunately,
the overall incidence of skin
disorders is likely to increase as
the world population continues to
age. In the United States, it is
estimated that the number of
people 65 and older will double
from 41 million in the year 2010
to 86 million by the year 2050.11
Consequently, there will be a
substantial increase in age-related
dermatologic diseases and
conditions in the future.
ACTINIC PURPURA
Mature skin is often prone to
significant bruising due to
reduction in connective tissue,
loss of subcutaneous fat to
support the skin structure,
flattening of the dermal junction,
and effacement of the dermal
papillae. The connective tissue of
the dermis is no longer able to
adequately support the
microvasculature. Consequently,
minor trauma can rupture blood
vessels, leading to extravasation
of blood. This age-related
condition is called actinic
purpura. Also known as senile
purpura,12 solar purpura,13
traumatic purpura, and Bateman’s
disease,14 it is characterized by
unsightly ecchymoses and purple
patches on the arms or legs of
elderly persons caused by blood
extravasation following minor
trauma.
Actinic purpura occurs almost
exclusively among the elderly
population, although it may
occasionally occur in younger
people. Similar to other skin
conditions, the incidence of
actinic purpura increases with
advancing age and occurs with
equal frequency among men and
women. One source suggests
actinic purpura affects
approximately two percent of
people 60 to 70 years old,
increasing to as many as 25
percent of people in the 90- to
100-year age group. Another
suggests actinic purpura affects
less than 10 percent of people
over 50 years old. It is closely
associated with photoaged skin15
and may be worse among people
taking aspirin, nonsteroidal anti-
inflammatory drugs, or
anticoagulants. Treatment is
usually unnecessary and
complications are rarely
reported.16 Following
extravasation, blood is typically
resorbed in 10 to 14 days.17
Delayed resorption for as long as
three weeks may be due to the
absence of a normal phagocytic
response. Post-inflammatory
hyperpigmentation may occur.
ACTINIC PURPURA AND QUALITY
OF LIFE
The consequences of
photodamaged skin include
increased rhytides, pigmentary
changes, skin laxity and
roughness, and telangiectasias,
which may have a negative
impact on overall quality of life
including interpersonal
interactions and self-esteem.1 8
Similarly, actinic purpura is a
cosmetic condition that can also
be associated with significant
psychological distress.12 Its
unattractive appearance may lead
to aversion by others.19 While not
a dangerous condition, effective
treatment of actinic purpura is of
great clinical importance for the
wellbeing of the elderly patient.
PRIOR TREATMENTS FOR ACTINIC
PURPURA
Published work describing
available treatments for actinic
purpura are limited. In one small,
double-blind study (N=14),
healthy subjects 60 to 80 years
old with at least two actinic
purpura lesions of approximately
equal size on each forearm were
enrolled. Subjects were
randomized to receive twice-daily
treatment with 0.1% retinoic acid
cream or non-medicated vehicle
on each arm for 16 weeks.17 After
two weeks of treatment, there
were fewer lesions on the retinoic
acid-treated arm (p<0.05);
however, there were no
significant differences after that
time.
More recently, a small open-
label study assessed the
effectiveness of human epidermal

4646 JCAD journal of clinical and aesthetic dermatology June 2017 • Volume 10 • Number 6
R E V I E W
growth factor for the treatment of
actinic purpura when applied
twice daily for six weeks (N=6).12
Ultrasound measurements
indicated a mean (SEM) skin
thickening of 195.2 (35.7) m
while the mean number of
purpuric lesions decreased from
15 (4.6) to 2.3 (0.7) over the same
time period.
NEW MOISTURIZING BRUISE
FORMULA
A new moisturizing bruise
product (DerMend®, Ferndale
Healthcare) has been formulated
specifically for the treatment of
actinic purpura. This product
contains ingredients that
effectively treat actinic purpura
by improving local circulation,
thickening the skin, and repairing
the skin barrier. Each of these
ingredients and their known
beneficial effects are described in
detail below.
Retinol. Numerous studies
have demonstrated the beneficial
effects of topical retinol, a
precursor of retinoic acid. In one
study, retinol 0.1% was applied to
the skin of healthy women 35 to
55 years old (N=41) every other
day for two weeks, then daily for
10 additional weeks. This
treatment increased epidermal
thickness, and upregulated genes
for collagen type 1, and collagen
type 3 with corresponding
increases in procollagen I and
procollagen 3 protein expression
and a significant reduction in
facial wrinkles.20 Similarly, the
topical application of 0.1%
retinol in another study increased
keratinocyte proliferation and
epidermal thickness and
improved major signs of skin
aging.21
A 52-week, double-blind,
vehicle-controlled study
demonstrated the ability of a
retinol 0.1% formulation to
significantly improve the
appearance of photodamaged skin
including a 44-percent
improvement in lateral canthal
fine lines and an 84-percent
improvement in the appearance of
mottled skin.22 Histology studies
demonstrated increased
expression of type 1 procollagen,
hyaluronan, and Ki67, a marker
for cell proliferation. When
combined with a vitamin C-
containing moisturizer, the
application of topical retinol
0.1% for 12 weeks improved the
appearance of women with mild-
to-moderate hyperpigmented and
photodamaged facial skin.23
While no study has assessed
the effects of retinol for the
treatment of actinic purpura, the
combination of topical 0.3%
retinol and 1% vitamin K
shortened the duration of laser-
induced purpura when applied for
two weeks prior and two weeks
after undergoing treatment with a
pulsed dye laser.24
Alpha hydroxy acids.
DerMend contains glycolic
compound 4.4, a combination of
glycolic acid and ammonium
glycolate. Products containing the
α-hydroxy acids glycolic acid and
lactic acid and the b-hydroxy acid
salicylic acid have been used for
treating cosmetic skin conditions,
such as seborrheic keratoses,
melasma, actinic keratoses, and
verrucae vulgares, and the
rejuvenation of photoaged skin,
for many years.25,26
In vitro studies have shown
that dermal fibroblasts grown in
the presence of glycolic acid for
24 hours resulted in increased
collagen production.27 Clinically,
measured improvements in skin
quality include decreased skin
roughness, skin dryness,
discoloration, solar keratoses, and
overall pigmentation, increased
collagen I and procollagen I, and
improved quality of elastic skin
bers.25,28,29 The long-term use of
an α-hydroxy acid-containing
product resulted in significant
clinical improvements in facial
skin tone and fine wrinkling,
which were associated with
psychosocial benefits.30
Arnica oil. Arnica oil is
derived from the medicinal plant
Arnica montana L. Extracts of A.
montana are rich in flavonoids
and phenolic acids and
demonstrate antioxidant activity
in vitro and protection against
oxidative damage in fibroblast-
like cells.31 The topical
application of an A. montana-
containing gel demonstrated
beneficial effects on experimental
wound healing in an animal
model32 and an A. montana-
containing ointment improved
pulsed-dye laser-induced bruising
in human volunteers.33
Ceramides. The barrier
function of the stratum corneum
is dependent on the presence of a
lipid matrix that includes the
epidermal sphingolipid
ceramides.34,35 As a result of skin
barrier defects, up to 75 percent

4747
JCAD journal of clinical and aesthetic dermatology June 2017 • Volume 10 • Number 6
R E V I E W
of elderly patients are affected by
xerosis.36 Ceramides also play a
role in the differentiation of
keratinocytes and regulation of
cell signaling.37 DerMend
contains a proprietary blend of
specifically targeted ceramides
(ceramide NP, ceramide NS,
ceramide EOS, ceramide EOP,
and ceramide AP), and several
studies have demonstrated the
beneficial effects of this
combination of ceramides in
mature skin.
Using an in vitro model, the
effects of the ceramides
phytosphingosine, sphingosine,
sphinganine and their hexanoyl-,
stearoyl- and salicyl-derivatives
were assessed using human
keratinocytes.3 7 Most of these
substances were found to be
potent promoters of keratinocyte
differentiation. Improvements in
skin barrier function have been
demonstrated following the
topical application of physiologic
amounts of the ceramides
sphingosine, phytosphingosine,
esterified fatty acids, omega
hydroxy fatty acids, normal fatty
acids, and alpha-hydroxy fatty
acid in human volunteers.38
A controlled clinical trial
assessed the beneficial effects of
a ceramide 3-containing emollient
using an experimental skin barrier
dysfunction model in healthy
volunteers.39 Skin barrier
dysfunction was caused by tape
stripping, which resulted in
erythema and increased
transepidermal water loss
associated with up-regulation of
cycling cells, involucrin, and
expression of cytokeratin-16.
Half the injured areas were
treated once daily with the test
product for five days. On Day 4,
the ceramide-containing
emollient significantly decreased
erythema, transepidermal water
loss, and cycling cells vs. the
untreated site.
Niacinamide. Niacinamide (or
niacin) is a form of vitamin B3
with antioxidant properties that
help improve skin appearance. It
regulates poly-ADP ribose-
polymerase 1, an enzyme with
important roles in DNA repair
and the expression of
inflammatory cytokines.40
Niacinamide has been shown to
increase the beneficial effects of
moisturizers for treating xerosis
by improving the integrity of the
stratum corneum41 and increasing
corneal hydration.42–44
The application of niacinamide
can also improve the appearance
of fine lines and wrinkles,45,46
hyperpigmentation spots, texture,
red blotchiness, and sallowness.46
In one randomized clinical trial,
female subjects (N=50) with
signs of facial photoaging
including fine lines and wrinkles,
poor texture, and hyperpigmented
spots applied 5% niacinamide to
half of the face and its vehicle
control to the other half twice
daily for 12 weeks.47 Facial
images and instrumental
measures were obtained at
baseline and at four-week
intervals. Significant
improvements in skin appearance
included reduction in fine lines
and wrinkles, hyperpigmented
spots, red blotchiness,
sallowness, and skin elasticity.
Interestingly, oral nicotinamide
Figure 1. The appearance of actinic purpura (left) is greatly improved after treatment for 56 days (right).

4848 JCAD journal of clinical and aesthetic dermatology June 2017 • Volume 10 • Number 6
has recently been shown to be
effective for reducing
nonmelanoma skin cancers and
actinic keratoses in high-risk
patients.4 8
Phytonadione. Topically
applied phytonadione, or vitamin
K1, has been shown to have
beneficial effects on injured skin.
Using an animal model, a topical
vitamin K cream increased
experimental wound healing.49
Clinically, topical vitamin K
enhanced the healing of bruises
caused by laser treatment. In one
randomized, double-blind,
placebo-controlled study (N=22),
subjects applied vitamin K cream
to one side of their face for two
weeks before and/or two weeks
after laser treatment for facial
telangiectases using a 585nm
pulsed dye laser.50 There was no
difference in the extent of
bruising on the topical vitamin K-
treated sides; however, the
severity of bruising was
significantly less on the vitamin
K-treated sides. In a similar
randomized, controlled study, the
application of vitamin K gel
following pulsed dye laser
treatment shortened the time for
resolution of facial bruising.51
RECOMMENDATIONS FOR THE
TREATMENT OF ACTINIC PURPURA
My personal observation is that
DerMend is very effective for the
treatment of actinic purpura. My
patients are exceedingly pleased
with the results they have
achieved as shown in Figures 1
and 2. I recommend that patients
treat their hands and forearms
where sun damage is more
pronounced and where the skin is
thinner and skin injury is more
likely to occur. For some patients,
this may also include the lower
legs. The product should be
applied to all areas twice daily to
improve skin quality and prevent
or minimize future lesions and
three times daily on bruised areas
to improve healing. Sunscreens
that provide both UVA and UVB
protection should be applied
daily, especially to affected areas.
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Figure 2. The appearance of actinic purpura (left) is greatly improved after treatment for 26 days (right).

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