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Pigmented purpuric eruption associated with injection medroxyprogesterone acetate
BRIEF
REPORTS
Pigmented purpuric eruption associated with injection medroxyprogesterone acetate Hensin Tsao, MD, PhD,a and Lisa H. Lerner, MDb Boston, Massachusetts Pigmented purpuric eruptions are characterized clinically by purpura, most commonly petechial, and brownish pigmentation. Although there are several idiopathic variants, several drugs have been associated with these eruptions. We present a patient who experienced pigmented purpura on her lower extremities several months after initiating medroxyprogesterone acetate injection. The eruption cleared several weeks after discontinuation of the medication. (J Am Acad Dermatol 2000;43:308-10.)
W
e describe a patient who experienced a pigmented purpuric eruption after starting treatment with medroxyprogesterone acetate injection.
CASE REPORT A 32-year-old woman presented to the dermatology clinic with a 1-month history of an asymptomatic rash on her lower extremities. Her medical history was significant only for cervical dysplasia and occasional back pain. Approximately 4 months before the onset of her eruption, she began receiving medroxyprogesterone acetate injections to regulate her menstrual periods; she had not taken other medications. On physical examination, the patient had an eruption localized to both lower extremities (Fig 1). The rash was composed of scattered, irregularly configured patches of coalescent petechiae and telangiectases. Diascopy yielded residual pigmentation within these patches. The rest of her physical examination was unremarkable. A specimen from a punch biopsy revealed a mononuclear cell infiltrate around papillary dermal capillaries with prominent extravasation of erythrocytes (Fig 2). No fibrinoid material was present in or around vessels. A mild vacuolar interface dermatitis was noted in the overlying epidermis. The patient discontinued the medroxyprogesterone acetate and was prescribed fluocinonide cream to be applied once daily. Follow-up evaluation at 6 weeks revealed that the rash had largely cleared.
DISCUSSION
From the Departments of Dermatologya and Pathology,b Massachusetts General Hospital. Reprints not available from authors. Copyright © 2000 by the American Academy of Dermatology, Inc. 0190-9622/2000/$12.00 + 0 16/54/106372 doi:10.1067/mjd.2000.106372
We present an unusual case of pigmented purpura that occurred several months after initiating medroxyprogesterone acetate injection. The history supports an association, in this person, between the use of medication and the rash. She was completely healthy during the course of her disease, she was not
308
Fig 1. Petechial and pigmented patches located on both lower extremities.
J AM ACAD DERMATOL VOLUME 43, NUMBER 2, PART 1
Brief reports 309
Fig 2. Photomicrograph of biopsy specimen demonstrates mononuclear cell inflammation around dermal capillaries with mild vacuolar interface dermatitis. Prominent extravasation of erythrocytes without fibrinoid material in or around the vessel.
receiving other medications at the time, and her skin cleared after the injections had been discontinued. Drug-induced pigmented purpura is rare. The onset of rash from drug exposure has been reported to range from weeks1 to years.2 Histologically, drug-induced pigmented purpuric eruptions resemble other idiopathic variants. Medications that have been associated with pigmented purpura include thiamine propyldisulfide, chlordiazepoxide,2 carbromal, meprobamate,3 glipizide,1 thiamine,4 pefloxacin, lorazepam, aspirin,5 and acetaminophen.6 Intravenous injection of polyvinylpyrrolidone, a plasma expander, has led to pigmented purpuric dermatoses among other cutaneous findings. However, biopsy specimens from the skin of polyvinylpyrrolidone-exposed patients reveal characteristic blue-gray vacuolated cells around blood vessels rather than the classic lymphocytic capillaritis.7 Finally, topical exposure to fluorouracil has also been associated with pigmented purpuric eruptions.8 Central to the pathogenesis of pigmented purpuric eruptions is a lymphocytic capillaritis. The pigmentation and purpura result from the vascular injury and erythrocyte extravasation. Several variants of pigmented purpura have been described, including Schamberg’s progressive pigmentary dermatosis, purpura annularis telangiectoides, pigmented purpuric lichenoid dermatitis, eczematoid pigmented purpuric dermatitis of Doucas and Kapetanakis, and lichen aureus.9 Pigmented purpura-like rashes have
also been reported to predate the onset of mycosis fungoides.5,10 Most cases of pigmented purpuric eruptions will clear spontaneously, although relapses may occur indefinitely.11 Our patient cleared after discontinuation of her medication and a brief course of topical steroids. Other reported treatments for pigmented purpuric eruptions have included cyclosporine,12 griseofulvin,13 and PUVA.14 REFERENCES 1. Adams BB, Gadenne AS. Glipizide-induced pigmented purpuric dermatosis. J Am Acad Dermatol 1999;41:827-9. 2. Nishioka K, Katayama I, Masuzawa M, Yokozeki H, Nishiyama S. Drug-induced chronic pigmented purpura. J Dermatol 1989;16: 220-2. 3. Peterson WC Jr, Manick KP. Purpuric eruptions associated with use of carbromal and meprobamate. Arch Dermatol 1967;95: 40-2. 4. Nishioka K, Sarashi C, Katayama I. Chronic pigmented purpura induced by chemical substances. Clin Exp Dermatol 1980;5: 213-8. 5. Lipsker D, Cribier B, Heid E, Grosshans E. Cutaneous lymphoma manifesting as pigmented, purpuric capillaries. Ann Dermatol Venereol 1999;126:321-6. 6. Kwon SJ, Lee CW. Figurate purpuric eruptions on the trunk: acetaminophen-induced rashes. J Dermatol 1998;25:756-8. 7. Kuo TT, Hu S, Huang CL, Chan HL, Chang MJ, Dunn P, et al. Cutaneous involvement in polyvinylpyrrolidone storage disease: a clinicopathologic study of five patients, including two patients with severe anemia. Am J Surg Pathol 1997;21:1361-7. 8. Voelter WW. Pigmented purpuric dermatosis-like reaction to topical fluorouracil. Arch Dermatol 1983;119:875-6.
310 Brief reports
9. Newton RC, Raimer SS. Pigmented purpuric eruptions. Dermatol Clin 1985;3:165-9. 10. Barnhill RL, Braverman IM. Progression of pigmented purpuralike eruptions to mycosis fungoides: report of three cases. J Am Acad Dermatol 1988;19:25-31. 11. Ratnam KV, Su WP, Peters MS. Purpura simplex (inflammatory purpura without vasculitis): a clinicopathologic study of 174 cases. J Am Acad Dermatol 1991;25:642-7. 12. Okada K, Ishikawa O, Miyachi Y. Purpura pigmentosa chronica successfully treated with oral cyclosporin A [letter]. Br J Dermatol 1996;134:180-1.
J AM ACAD DERMATOL AUGUST 2000
13. Tamaki K, Yasaka N, Osada A, Shibagaki N, Furue M. Successful treatment of pigmented purpuric dermatosis with griseofulvin. Br J Dermatol 1995;132:159-60. 14. Krizsa J, Hunyadi J, Dobozy A. PUVA treatment of pigmented purpuric lichenoid dermatitis (Gougerot-Blum) [see comments]. J Am Acad Dermatol 1992;27:778-80.
REPORTS
Pigmented purpuric eruption associated with injection medroxyprogesterone acetate Hensin Tsao, MD, PhD,a and Lisa H. Lerner, MDb Boston, Massachusetts Pigmented purpuric eruptions are characterized clinically by purpura, most commonly petechial, and brownish pigmentation. Although there are several idiopathic variants, several drugs have been associated with these eruptions. We present a patient who experienced pigmented purpura on her lower extremities several months after initiating medroxyprogesterone acetate injection. The eruption cleared several weeks after discontinuation of the medication. (J Am Acad Dermatol 2000;43:308-10.)
W
e describe a patient who experienced a pigmented purpuric eruption after starting treatment with medroxyprogesterone acetate injection.
CASE REPORT A 32-year-old woman presented to the dermatology clinic with a 1-month history of an asymptomatic rash on her lower extremities. Her medical history was significant only for cervical dysplasia and occasional back pain. Approximately 4 months before the onset of her eruption, she began receiving medroxyprogesterone acetate injections to regulate her menstrual periods; she had not taken other medications. On physical examination, the patient had an eruption localized to both lower extremities (Fig 1). The rash was composed of scattered, irregularly configured patches of coalescent petechiae and telangiectases. Diascopy yielded residual pigmentation within these patches. The rest of her physical examination was unremarkable. A specimen from a punch biopsy revealed a mononuclear cell infiltrate around papillary dermal capillaries with prominent extravasation of erythrocytes (Fig 2). No fibrinoid material was present in or around vessels. A mild vacuolar interface dermatitis was noted in the overlying epidermis. The patient discontinued the medroxyprogesterone acetate and was prescribed fluocinonide cream to be applied once daily. Follow-up evaluation at 6 weeks revealed that the rash had largely cleared.
DISCUSSION
From the Departments of Dermatologya and Pathology,b Massachusetts General Hospital. Reprints not available from authors. Copyright © 2000 by the American Academy of Dermatology, Inc. 0190-9622/2000/$12.00 + 0 16/54/106372 doi:10.1067/mjd.2000.106372
We present an unusual case of pigmented purpura that occurred several months after initiating medroxyprogesterone acetate injection. The history supports an association, in this person, between the use of medication and the rash. She was completely healthy during the course of her disease, she was not
308
Fig 1. Petechial and pigmented patches located on both lower extremities.
J AM ACAD DERMATOL VOLUME 43, NUMBER 2, PART 1
Brief reports 309
Fig 2. Photomicrograph of biopsy specimen demonstrates mononuclear cell inflammation around dermal capillaries with mild vacuolar interface dermatitis. Prominent extravasation of erythrocytes without fibrinoid material in or around the vessel.
receiving other medications at the time, and her skin cleared after the injections had been discontinued. Drug-induced pigmented purpura is rare. The onset of rash from drug exposure has been reported to range from weeks1 to years.2 Histologically, drug-induced pigmented purpuric eruptions resemble other idiopathic variants. Medications that have been associated with pigmented purpura include thiamine propyldisulfide, chlordiazepoxide,2 carbromal, meprobamate,3 glipizide,1 thiamine,4 pefloxacin, lorazepam, aspirin,5 and acetaminophen.6 Intravenous injection of polyvinylpyrrolidone, a plasma expander, has led to pigmented purpuric dermatoses among other cutaneous findings. However, biopsy specimens from the skin of polyvinylpyrrolidone-exposed patients reveal characteristic blue-gray vacuolated cells around blood vessels rather than the classic lymphocytic capillaritis.7 Finally, topical exposure to fluorouracil has also been associated with pigmented purpuric eruptions.8 Central to the pathogenesis of pigmented purpuric eruptions is a lymphocytic capillaritis. The pigmentation and purpura result from the vascular injury and erythrocyte extravasation. Several variants of pigmented purpura have been described, including Schamberg’s progressive pigmentary dermatosis, purpura annularis telangiectoides, pigmented purpuric lichenoid dermatitis, eczematoid pigmented purpuric dermatitis of Doucas and Kapetanakis, and lichen aureus.9 Pigmented purpura-like rashes have
also been reported to predate the onset of mycosis fungoides.5,10 Most cases of pigmented purpuric eruptions will clear spontaneously, although relapses may occur indefinitely.11 Our patient cleared after discontinuation of her medication and a brief course of topical steroids. Other reported treatments for pigmented purpuric eruptions have included cyclosporine,12 griseofulvin,13 and PUVA.14 REFERENCES 1. Adams BB, Gadenne AS. Glipizide-induced pigmented purpuric dermatosis. J Am Acad Dermatol 1999;41:827-9. 2. Nishioka K, Katayama I, Masuzawa M, Yokozeki H, Nishiyama S. Drug-induced chronic pigmented purpura. J Dermatol 1989;16: 220-2. 3. Peterson WC Jr, Manick KP. Purpuric eruptions associated with use of carbromal and meprobamate. Arch Dermatol 1967;95: 40-2. 4. Nishioka K, Sarashi C, Katayama I. Chronic pigmented purpura induced by chemical substances. Clin Exp Dermatol 1980;5: 213-8. 5. Lipsker D, Cribier B, Heid E, Grosshans E. Cutaneous lymphoma manifesting as pigmented, purpuric capillaries. Ann Dermatol Venereol 1999;126:321-6. 6. Kwon SJ, Lee CW. Figurate purpuric eruptions on the trunk: acetaminophen-induced rashes. J Dermatol 1998;25:756-8. 7. Kuo TT, Hu S, Huang CL, Chan HL, Chang MJ, Dunn P, et al. Cutaneous involvement in polyvinylpyrrolidone storage disease: a clinicopathologic study of five patients, including two patients with severe anemia. Am J Surg Pathol 1997;21:1361-7. 8. Voelter WW. Pigmented purpuric dermatosis-like reaction to topical fluorouracil. Arch Dermatol 1983;119:875-6.
310 Brief reports
9. Newton RC, Raimer SS. Pigmented purpuric eruptions. Dermatol Clin 1985;3:165-9. 10. Barnhill RL, Braverman IM. Progression of pigmented purpuralike eruptions to mycosis fungoides: report of three cases. J Am Acad Dermatol 1988;19:25-31. 11. Ratnam KV, Su WP, Peters MS. Purpura simplex (inflammatory purpura without vasculitis): a clinicopathologic study of 174 cases. J Am Acad Dermatol 1991;25:642-7. 12. Okada K, Ishikawa O, Miyachi Y. Purpura pigmentosa chronica successfully treated with oral cyclosporin A [letter]. Br J Dermatol 1996;134:180-1.
J AM ACAD DERMATOL AUGUST 2000
13. Tamaki K, Yasaka N, Osada A, Shibagaki N, Furue M. Successful treatment of pigmented purpuric dermatosis with griseofulvin. Br J Dermatol 1995;132:159-60. 14. Krizsa J, Hunyadi J, Dobozy A. PUVA treatment of pigmented purpuric lichenoid dermatitis (Gougerot-Blum) [see comments]. J Am Acad Dermatol 1992;27:778-80.