John R. Tkach, M.D.
300 North Willson, Suite 203B
Bozeman, MT 59715
(406) 587-5442

Bateman's Purpura (Solar Purpura, Senile Purpura)

Patient Information Sheet

Everyday in my clinic, I see patient after patient for precancerous skin lesions called actinic keratoses. A lot of these people also point to dark purple bruises and lacerations and tears of the fragile skin on the backs of their forearms and hands. Eventually, the bruising leads to a brown staining on the arms. The bruises heal in about three weeks, but the brown color may linger.

Thomas Bateman first reported this condition in 1813. Bateman's purpura occurs in about 12% of people over age 50. I think I see it mostly in people in their 70's and 80's when it is noted in 29% of people according to one account. But reports vary. Another estimate was 2% of people 60-70 years old have it.

Purpura means bruising. In Bateman's purpura small injuries cause blood to leak out of the microscopic capillary blood vessels of the skin more easily than it should. When the body heals the bruises, some red blood cell iron (iron in hemoglobin) is left behind causing a brown stain in the skin like a tattoo. Blood belongs inside blood vessels, not loose in the tissues. It is irritating when it is extravasated into the tissues outside the blood vessels. That's why a hemorrhagic ruptured tubal pregnancy is so painful.

The same sun damage that causes the easy bruising, causes fragile skin that tears even with minor bumps. It is disconcerting to experience this. Taxicab drivers are prone to getting Bateman's purpura on the arm that is on the window side of their cabs.

Back in the 1970's and 1980's I used to think Bateman's purpura was due to ageing and taking blood thinners to prevent stroke and heart attack. Anticoagulant medicines include aspirin, Coumadin or warfarin, and ibuprofen. I told them that it was a small price to pay for preventing stroke. In retrospect, I think that answer, while true, was insensitive. Having Bateman's purpura makes people feel older and less healthy that they really are. Each time they see these bruises, it makes them feel a little bad and self-conscious. The lacerations are vulnerable to infection.

Then starting about 1985, I rethought Bateman's purpura. By 1983, Retin A was being used to reverse some of the wrinkles people get on their faces from sun damage. I realized that wrinkles are in large part due to sun. The only correlation with age was the older you are the more opportunities you have had to be in the sun.

Now that is not the whole story. There is a tendency to lose collagen connective tissue as a part of ageing. Some estimates are as high as 1% a year, but I could not confirm that.

I wondered, if Retin A could help repair sun damage on the face, could it help Bateman's purpura? I started prescribing it for a few people with Bateman's purpura. I found that using Retin A daily for two years made the purpura and fragility much better. Retin A is just a cream containing a vitamin-A-derivative called retinoic acid. Plain vitamin A cream will not help. It has to be Retin A.

I have really great news. A new form of Retin A called Retin A Micro works even better. Some patients are getting good improvement in as little as four months. But you should be prepared to use it for a year or two. And there is no guarantee that it will work. If improving the bruising and fragility of the skin on the backs of your hands and forearms will make you feel better, I think it's worth trying.

What's Going on and What Does Retin A Do About It?

The main layer of the skin is the dermis. It contains the protein molecules collagen and elastin that give the skin its strength and stretch. Think of a bundle of rubber bands stretched out. Now imagine cutting the rubber bands in the middle. They twang back and roll up into balls. That's what's happening with sun damage. The ultraviolet light cuts the collagen and elastin molecules. Under the microscope with special preparation, we see round balls of pale dermis.

These same proteins make a protective casing around the microscopic capillary blood vessels. The collagen and elastin give a protective coating to the small blood vessels. Without that protective covering, the blood vessels are vulnerable and bleed from minor injuries.

What we need to do is to restore that protective protein around the little blood vessels. Retin A does something that probably helps fibroblast cells to repair the broken collagen and elastin molecules. Or at least it helps the fibroblasts to make new proteins and repair the damaged support tissue layer. That's also what it does to reverse wrinkles. I think it works better for Bateman's purpura than it does for wrinkles.

How Do You Say That In Scientific Terms?

Menditto and Borrelli expressed it eloquently. "The Authors consider this disease an expression of amyloidosic character of all the vessel structures, of senile elastosis and of the lack of fibrin-like material."

What's So Special About Retin A Micro?

Why not just use the cheaper plain Retin A or a generic retinoic acid? Almost all topical medicines such as cortisone creams and antibiotics enter the skin quickly, work for 45 minutes, and then they are done. No more treatment is going on from that application. Out of 24 hours, you are getting less than one hour of actual treatment. That's not much.

Because the regular Retin A treatment is so intense for that 45 minutes time, it is irritating. And this is the most common complaint with using Retin A or retinoic acid cream. It is like passing a flame thrower over your skin. Kind of like making crème brulee.

But Retin A Micro is different. It looks like a cream, but it has no cream or ointment in it. It just contains microscopic little sponges loaded with Retin A. The medicine is the same, but the way it is packaged at the microscopic level is different. It has millions of beads with tiny holes that are loaded with Retin A and slowly leak out the medicine a few molecules at a time from each bead. It keeps working 8 hours, not just 45 minutes.

By spreading the dosing out over such a long time, you avoid that flame-thrower irritation effect. In my experience, Retin A Micro just works better. You get 10.66 times more treatment with the Retin A Micro. It is superior. What' the catch? It is expensive. But your insurance may help.

How Do You Use Retin A Micro for Bateman's Purpura?

Put it on at bedtime with your skin dry. Rub in a thin layer. If you take a shower at bedtime, wait 15 minutes for your skin to dry before putting on Retin A Micro. Your skin needs a few weeks to adjust to Retin A Micro.

The first week use it every 3rd night.
Second week apply it every other night.
If that is not too irritating, the 3rd week try it every night.

If every night is too irritating, go back to every other night.

Retin A Micro comes in two strengths 0.04% and 0.1%. I rarely run into irritation with the 0.04%. If 0.04% is not too irritating and you want to try the stronger 0.1% let me know as we go along. Start with the smallest tube while you find out what concentration you can use.

How Long Will You Need to Use Retin A Micro?

With the old form of plain Retin A it took about 2 years. I do not have enough experience with the Retin A Micro to answer the question. But I have seen excellent improvement in 4 months for a few patients.

Other Considerations

Do you have von Willebrand's disease or haemophilia?

Primary systemic amyloidosis and pseudoxanthoma elasticum can look similar, but those are rare. I have only seen one case each in 42 years.

We should check your platelet count or get a CBC.

Since sunlight caused this in the first place, you should use sun protective clothing and a strong sunscreen such as Neutrogena Dry Touch SPF 100+

Drugs That Contribute to Bleeding and Bruising

NSAID's, prednisone, anticoagulants like heparin and warfarin, some cancer chemotherapy and some foods can contribute to easy bleeding. Let me know if you are taking any of these listed below. But do not stop taking your medicine.

References:

I did a thorough literature search at the university library. I searched MEDLINE via First Search, by Web of Science, and did Up To Date, and Google Scholar. The literature on this topic is not robust probably because Bateman's purpura does not kill people and so does not get much attention.

  1. Joshi et al, Unilateral solar purpura as a manifestation of asymmetrical photodamage in taxi drivers, Arch. Derm. 1996, vol 132(6): 715-716.
  2. Menditto and Borrelli, Bateman's Disease, Pathologica 1994 Dec.; 86(6) 645-8.
  3. Schwartz, Robert, Actinic Purpura, Medscape, Sept 4, 2013
  4. Rallis , et al, Effects of 0.1%retinoic acid on Bateman's actinic purpra, Arch. Derm. 1995; 13(4): 493-495.
  5. Waters et al, Solar capillaritis as a cause of solar purpura, Clinical and Experimental Dermatology 2009; 34, e821-e824

The information provided in these patient information sheets is offered for general informational and educational purposes only; it is not offered as and does not constitute medical advice. In no way are any of the materials presented meant to be a substitute for professional medical care or attention by a qualified practitioner, nor should they be construed as such.

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