Evaluation of purpura in children
- Leslie Raffini, MD
Leslie Raffini, MD
- Associate Professor of Pediatrics
- University of Pennsylvania
- Section Editor
- Gary R Fleisher, MD
Gary R Fleisher, MD
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Pediatric Signs and Symptoms
- Egan Family Foundation Professor
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Bleeding under the skin or into mucosal membranes is called purpura and may be an innocent finding related to mild childhood trauma or may be the presenting sign of a life threatening disease. Purpura can be subdivided based on size into petechiae (picture 1) and ecchymoses (picture 2) . Pinpoint areas (less than 2 mm) of hemorrhage, which are reddish-purple lesions are called petechiae (picture 1), while larger confluent lesions are referred to as ecchymoses (picture 2). Ecchymoses are commonly called bruises. In some cases, ecchymoses may be tender or raised. In contrast to other erythematous or vascular skin lesions, purpuric lesions do not blanch when pressure is applied to the skin.
Careful evaluation of any patient with purpura is important for early diagnosis and treatment, particularly in children who are ill-appearing. The type, location, and extent of the purpura, along with the overall appearance of the child, will help guide the initial evaluation.
This review will discuss the evaluation of purpura in children. The evaluation of bleeding in children and adults is discussed separately. (See "Approach to the child with bleeding symptoms" and "Approach to the adult patient with a bleeding diathesis".)
Purpura may result from disruptions in vascular integrity (trauma, infection, vasculitis, collagen disorders) or may be due to abnormalities in primary or secondary hemostasis (thrombocytopenia, abnormal platelet function, clotting factor deficiency, or abnormal clotting factor function) .
Complex mechanisms maintain vascular integrity and limit the flow of blood when a blood vessel is damaged:
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- DISRUPTIONS IN VASCULAR INTEGRITY
- Henoch-Schönlein purpura (IgA vasculitis)
- Drug-induced vasculitis
- Neonatal purpura fulminans
- Vitamin C deficiency
- Ehlers-Danlos syndrome
- DISORDERS OF HEMOSTASIS
- - Immune thrombocytopenia (ITP)
- - Hemolytic uremic syndrome
- - Thrombotic thrombocytopenic purpura
- - Disseminated intravascular coagulation
- - Bone marrow infiltration
- - Neonatal alloimmune thrombocytopenia
- - Inherited thrombocytopenias
- - Drug induced thrombocytopenia
- - Bone marrow failure
- - Sequestration
- - Inherited platelet function abnormalities
- - Acquired platelet function abnormalities
- Clotting factor deficiencies
- - Von Willebrand disease
- - Hemophilia
- - Other congenital factor deficiencies
- - Vitamin K deficiency
- - Liver disease
- Disseminated intravascular coagulation (DIC)
- Physical examination
- Laboratory evaluation
- Appears ill
- Appears well
- - Thrombocytopenia
- - Normal platelet count, abnormal PT or aPTT
- - Normal platelet count, PT, and aPTT