Senile purpura (also known as "Actinic purpura," and "Solar purpura") was first described by Bateman1 in 1818 when he noted dark purple blotches and determined that they were due to the extravasation of blood into the dermal tissue. Patients with this condition develop persistent dark purple ecchymoses, which are characteristically confined to the extensor surfaces of the hands and forearms.2 Unlike other ecchymoses, which evolve into brown patches, senile purpura tends to fade to fainter shades of purple, although residual brown pigmentation may persist for weeks to months, or may be permanent.3,4 Although cosmetically displeasing, the disorder has no health consequences. Nevertheless, patients with senile purpura are often embarrassed by their purple blotches, and will tend to wear concealing clothing in an attempt to prevent exposure.

Causes
The purple ecchymoses and patches of this condition occur because red blood cells leak out of capillaries into the dermal tissue. This extravasation is secondary to the fragility of the blood vessel walls caused by chronic sun exposure with the resultant ultraviolet radiation, which induces dermal tissue atrophy. Because of the ultraviolet-induced atrophy, the connective tissue of the dermis is no longer able to adequately support the microvasculature. As a result, even minor trauma can tear the capillaries, leading to the extravasation of blood.5

Senile purpura may also be a sign of collagen loss in skin and bone. Women have less collagen than men and it decreases by one percent a year in exposed and unexposed skin. These changes in skin collagen may correspond to changes in bone density. It is hypothesized that changes in skin collagen also occur in bone collagen, leading to the associated changes in bone density.6

Epidemiology
In the United States, the occurrence of senile purpura is almost exclusively limited to the elderly population, commonly found in approximately 11.9 percent of those older than 50 years. Its prevalence markedly increases with years of exposure to the sun and is more pronounced in fair-skinned individuals than in others. Both sexes are equally affected.7

Conventional treatment
There is no conventional medicine for senile purpura.

Integrative treatment
Integrative treatment for senile purpura is effective, and may consist of using key nutraceuticals and one homeopathic remedy. Following is a discussion of these.

Vitamin C
Vitamin C is required for the synthesis of collagen, an important structural component of blood vessels, tendons, ligaments, and bone.8 Symptoms of scurvy, the classic vitamin C deficiency disease, include bleeding and bruising easily. These symptoms appear to be related to the weakening of blood vessels and connective tissue, both of which contain collagen.9 Consequently, maintaining healthy vitamin C status would appear to be an important consideration in the prevention of purpura. This was found to be the case in a double-blind, placebo-controlled trial10 of 94 elderly patients with initially low levels of vitamin C. After two months of vitamin C supplementation, clinical improvement was indicated by reductions in purpura and petechial hemorrhages (i.e., a small discrete capillary hemorrhage under the skin).

NOTE: Flavonoids help improve the absorption of vitamin C.11,12 Consequently, any of the following flavonoids have value from that perspective. In addition, they offer other benefits as indicated.

Rutin
Rutin is a flavonoid, an antioxidant, a free radical scavenger, and an iron-chelator.13,14 In solar purpura, the value of an antioxidant is to help reduce potential oxidative damage from the sun's UV-rays.

Furthermore, rutin has been reported to decrease capillary fragility and permeability.15 In an 8-month trial,16 oral treatment with rutin significantly decreased (P<0.05) in capillary filtration. In other research,17,18,19 treatment with rutin also significantly decreased capillary filtration.

Citrus bioflavonoids
Citrus bioflavonoids have antioxidant effects and include diosmin, eriodictyol, hesperidin, neohesperidoside, naringenin, eriocitrin, neodiosmin, rutinoside, chrysoeriol, isorhamnetin, limocitrin, limocitrol, isolimocitrol, and others.20,21 In animal models of diabetes, a diet containing citrus flavonoids consisting of 0.2 percent eriocitrin and 0.2 percent hesperidin results in reduced measures of oxidative stress after 28 days of treatment.22

Hesperidin
Hesperidin alone is frequently used for vascular conditions such as hemorrhoids and varicose veins since it helps improves venous tone, reduces stasis, restores normal capillary permeability, and improve lymphatic drainage. Hesperidin can also reduce the generation of free radicals.23,24,25,26 A randomized, controlled, crossover study27 also demonstrated that hesperidin provides vascular protective effects, including protective effects on the microvascular endothelium.

Eriocitrin
In animal research, the lemon flavonoid, eriocitrin was shown to be effective in the prevention of oxidative damage.28 Similar research demonstrated an increase in plasma antioxidant activity increased following oral administration of eriocitrin.29 Additional research has also shown eriocitrin's antioxidant activity.30

Arnica montana
The homeopathic remedy Arnica montana is commonly used to treat bruising. In a randomized, double-blind, placebo-controlled clinical trial,31 A. montana was used on 29 face-lift patients to assess efficacy in reducing bruising. The results were that patients treated with A. montana were found to have a smaller area of ecchymosis on postoperative days 1, 5, 7, and 10, with these differences reaching statistical significance on postoperative days 1 and 7.

A. montana's effectiveness in reducing bruising may be related to its ability to reduce bleeding. In another double blind, placebo-controlled, randomized, clinical trial,32 treatment with A. montana and Bellis perennis was found to reduce postpartum blood loss, as compared with placebo.

Combining rutin with vitamin C
In an open pilot study,33 oral rutin and vitamin C were administered to three patients with chronic progressive pigmented purpura (PPP), a different type of purpura. At the end of the 4-week treatment period, complete clearance of the skin lesions was achieved in all three patients. No adverse reactions were noted. All patients remained free of lesions at the end of 3-months treatment. A case report34 on another patient with PPP showed similar benefits when supplemented with rutin and vitamin C.

Combining vitamin C, rutin, citrus bioflavonoids, hesperidin, eriocitrin and A. montana
A six-week, randomized, multicenter, placebo-controlled, double-blind study35 was undertaken to evaluate the efficacy of a dietary supplement combining vitamin C, rutin, citrus bioflavonoids, hesperidin, eriocitrin and A. montana in the treatment of senile purpura. Seventy patients with senile purpura were enrolled and 67 completed the study. Subjects were randomized into two groups receiving either a supplement blend or placebo medication, which was taken orally twice daily for six weeks.

The results were a statistically significant reduction in the number of new purpura lesions in the skin area undergoing clinical study. At the end of six weeks, the supplement blend treated group showed a 50 percent reduction in purpura lesions from baseline. Patient self-assessment of the effectiveness of the medication echoed the results of an investigator global assessment with a statistically significant improvement in the skin's appearance noted by the patients receiving the supplement. No adverse effects were noted by either the patients or investigators. The authors of this study concluded that the supplement blend appears to both safely and effectively diminish skin bruising in patients with senile purpura.

Conclusion
Patients with senile purpura are often embarrassed by their purple blotches. Integrative treatment with vitamin C, key flavonids and the homeopathic A. montana has been show to result in a 50 percent reduction in skin purpura lesions.

References

  1. Bateman T. Exanthemata. In: A Practical Synopsis of Cutaneous Diseases. London, England: Longman, Hurst, Reese and Brown; 1818:118-9.
  2. The Merck Manual for Healthcare Professionals. Last full review/revision April 2009 by James N. George, MD. Content last modified April 2009. Retrieved January 12, 2012 from http://www.merckmanuals.com/professional/hematology_and_oncology/bleeding_due_to_abnormal_blood_vessels/senile_purpura.html?qt=solar%20purpura&alt=sh.
  3. Scheinfeld NS. Skin Disorders in Older Adults: Vascular, Lymphatic, and Purpuric Dermatitides, Part 1. Consultant. 2009 Jun 15;49(6). Retrieved January 12, 2012 from http://www.consultantlive.com/skin-diseases/content/article/10162/1421703#.
  4. The Merck Manual for Healthcare Professionals. Last full review/revision April 2009 by James N. George, MD. Content last modified April 2009. Retrieved January 12, 2012 from http://www.merckmanuals.com/professional/hematology_and_oncology/bleeding_due_to_abnormal_blood_vessels/senile_purpura.html?qt=solar%20purpura&alt=sh.
  5. Schwartz RA. Actinic Purpura Clinical Presentation. WebMD Professional. Updated April 25, 2011. Retrieved January 12, 2012 from http://emedicine.medscape.com/article/1087008-clinical#a0218.
  6. Shuster S. Osteoporosis, a unitary hypothesis of collagen loss in skin and bone. Med Hypotheses. 2005;65(3):426-32.
  7. Schwartz RA. Actinic Purpura. WebMD Professional. Updated April 25, 2011. Retrieved January 12, 2012 from http://emedicine.medscape.com/article/1087008-overview#a0199.
  8. Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr. 1999;69(6):1086-1107.
  9. Food and Nutrition Board, Institute of Medicine. Vitamin C. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington D.C.: National Academy Press; 2000:95-185.
  10. Schorah CJ, Tormey WP, Brooks GH, Robertshaw AM, Young GA, Talukder R, Kelly JF. The effect of vitamin C supplements on body weight, serum proteins, and general health of an elderly population. Am J Clin Nutr. 1981;34(5):871-6.
  11. Vinson JA, Bose P. Comparative bioavailability to humans of ascorbic acid alone or in a citrus extract. Am J Clin Nutr 1988;48:601-4.
  12. Vinson JA, Bose P. Comparative bioavailability of synthetic and natural vitamin C in guinea pigs. Nutr Rep Int 1983;27:875-9.
  13. Kostyuk VA, Potapovich AI. Antiradical and chelating effects in flavonoid protection against silica-induced cell injury. Arch Biochem Biophys 1998;355:43-8.
  14. Escarpa A, Gonzalez MC. High-performance liquid chromatography with diode-array detection for the determination of phenolic compounds in peel and pulp from different apple varieties. J Chromatogr A 1998;823:331-7.
  15. Leung AY, Foster S. Encyclopedia of Common Natural Ingredients Used in Food, Drugs and Cosmetics. 2nd ed. New York, NY: John Wiley & Sons, 1996.
  16. Cesarone MR, Belcaro G, Ippolito E, et al. Clinical improvement in chronic venous insufficiency signs and symptoms with Venoruton® (HR): an 8-month, open-registry, cost-efficacy study. Panminerva Med. 2010;52(2 Suppl 1):43-8.
  17. Belcaro G, Cesarone MR, Ledda A, et al. 5-Year control and treatment of edema and increased capillary filtration in venous hypertension and diabetic microangiopathy using O-(beta-hydroxyethyl)-rutosides: a prospective comparative clinical registry. Angiology. 2008;59 Suppl 1:14S-20S.
  18. Cesarone MR, Belcaro G, Ricci A, et al. Prevention of edema and flight microangiopathy with Venoruton (HR), (0-[beta-hydroxyethyl]-rutosides) in patients with varicose veins. Angiology. 2005 May-Jun;56(3):289-93.
  19. Cesarone MR, Belcaro G, Pellegrini L, et al. HR, 0-(beta-hydroxyethyl)-rutosides; (Venoruton): rapid relief of signs/symptoms in chronic venous insufficiency and microangiopathy: a prospective, controlled study. Angiology. 2005;56(2):165-72.
  20. Williams HL, Maher FT, Corbin KB, et al. Eriodictyol glycoside in the treatment of meni'ere's disease. Ann Otol Rhinol Laryngol 1963;72:1082-101.
  21. Ranganna S, Govindarajan VS, Ramana KV. Citrus fruits. Part II. Chemistry, technology, and quality evaluation. A. Chemistry. Critical Rev Food Sci Nutr 1983;19:313-86.
  22. Miyake Y, Yamamoto K, Tsujihara N, Osawa T. Protective effects of lemon flavonoids on oxidative stress in diabetic rats. Lipids 1998;33:689-95.
  23. Misra MC, Parshad R. Randomized clinical trial of micronized flavonoids in the early control of bleeding from acute internal haemorrhoids. Br J Surgery 2000;87:868-72.
  24. Cospite M. Double-blind, placebo-controlled evaluation of clinical activity and safety of Daflon 500 mg in the treatment of acute hemorrhoids. Angiology 1994;45:566-73.
  25. Di Carlo G, Mascolo N, Izzo AA, Capasso F. Flavonoids: Old and new aspects of a class of natural therapeutic drugs. Life Sci 1999;65:337-53.
  26. Koyuncu H, Berkarda B, Baykut F, et al. Preventive effect of hesperidin against inflammation in CD-1 mouse skin caused by tumor promoter. Anticancer Res 1999;19:3237-41.
  27. Morand C, Dubray C, Milenkovic D, Lioger D, Martin JF, Scalbert A, Mazur A. Hesperidin contributes to the vascular protective effects of orange juice: a randomized crossover study in healthy volunteers. Am J Clin Nutr. 2011;93(1):73-80.
  28. Minato K, Miyake Y, Fukumoto S, Yamamoto K, Kato Y, Shimomura Y, Osawa T. Lemon flavonoid, eriocitrin, suppresses exercise-induced oxidative damage in rat liver. Life Sci. 2003;72(14):1609-16.
  29. Miyake Y, Shimoi K, Kumazawa S, Yamamoto K, Kinae N, Osawa T. Identification and antioxidant activity of flavonoid metabolites in plasma and urine of eriocitrin-treated rats. J Agric Food Chem. 2000;48(8):3217-24.
  30. Davies N, Ohgami Y, Remsberg C, Yanez J. Eriocitrin and Eriodictyol: Anti-Cancer Activity, Anti-Oxidant Capacity, and Stereospecific Disposition in Rats, Humans, and Lemonade Tracks: Contributed Papers: In-Vivo Metabolism. 2006 AAPS Annual Meeting and Exposition. Monday, October 30, 2006. Retrieved January 12, 2012 from http://abstracts.aapspharmaceutica.com/expoaaps06/cc/forms/attendee/index.aspx?content=sessionInfo&sessionId=456.
  31. Seeley BM, Denton AB, Ahn MS, Maas CS. Effect of homeopathic Arnica montana on bruising in face-lifts: results of a randomized, double-blind, placebo-controlled clinical trial. Arch Facial Plast Surg. 2006;8(1):54-9.
  32. Oberbaum M, Galoyan N, Lerner-Geva L, Singer SR, Grisaru S, Shashar D, Samueloff A. The effect of the homeopathic remedies Arnica montana and Bellis perennis on mild postpartum bleeding--a randomized, double-blind, placebo-controlled study--preliminary results. Complement Ther Med. 2005;13(2):87-90.
  33. Reinhold U, Seiter S, Ugurel S, Tilgen W. Treatment of progressive pigmented purpura with oral bioflavonoids and ascorbic acid: an open pilot study in 3 patients. J Am Acad Dermatol. 1999;41(2 Pt 1):207-8.
  34. Laufer F. The treatment of progressive pigmented purpura with ascorbic acid and a bioflavonoid rutoside. J Drugs Dermatol. 2006;5(3):290-3.
  35. Berlin JM, Eisenberg DP, Berlin MB, Sarro RA, Leeman DR, Fein H. A randomized, placebo-controlled, double-blind study to evaluate the efficacy of a citrus bioflavanoid blend in the treatment of senile purpura. J Drugs Dermatol.
2011;10(7):718-22.

Gene Bruno, MS, MHS

Gene Bruno is the Dean of Academics and Professor of Dietary Supplement Science for Huntington College of Health Sciences (a nationally accredited distance learning college offering diplomas and degrees in nutrition and other health science related subjects. Gene has two undergraduate Diplomas in Nutrition, a Bachelor’s in Nutrition, a Master’s in Nutrition, a Graduate Diploma in Herbal Medicine, and a Master’s in Herbal Medicine. As a 32 year veteran of the Dietary Supplement industry, Gene has educated and trained natural product retailers and health care professionals, has researched and formulated natural products for dozens of dietary supplement companies, and has written articles on nutrition, herbal medicine, nutraceuticals and integrative health issues for trade, consumer magazines, and peer-reviewed publications. Gene's latest book, A Guide to Complimentary Treatments for Diabetes, is available on Amazon.com, and other fine retailers.