|Year : 2015 | Volume
| Issue : 2 | Page : 331-333
Oral Ecchymosis in elderly: Senile purpura
Srikanth H Srivathsa
Department of Oral Medicine and Radiology, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India
|Date of Submission||22-Jan-2015|
|Date of Acceptance||18-Oct-2015|
|Date of Web Publication||21-Nov-2015|
Srikanth H Srivathsa
Department of Oral Medicine and Radiology, Sri Hasanamba Dental College and Hospital, Vidyanagar, Hassan - 573 202, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Senile purpura is the clinical condition where purpuric spots and ecchymosis develop at the site of minimal injury. It occurs due to laxity of the connective tissue. Oral manifestation of this disease is rare and when one encounters such a case, proper examination with extensive differential diagnosis should be considered along with appropriate investigations. A case of senile purpura in an elderly patient who had developed oral ecchymosis secondary to denture injury is being reported.
Keywords: Ecchymosis, elderly, purpura, senile purpura
|How to cite this article:|
Srivathsa SH. Oral Ecchymosis in elderly: Senile purpura. J Indian Acad Oral Med Radiol 2015;27:331-3
| Introduction|| |
Senile purpura (SP) is the term used to describe ecchymosis/purpuric lesions that occur in the elderly individuals who are otherwise healthy. It generally occurs on the exposed surfaces of the extremities such as arms and legs or on the face following minor trauma.  SP is a benign condition, occurring primarily as a manifestation of aging, wherein the blood vessels lack adequate support from the underlying connective tissue and exhibit increased capillary fragility.  Bateman is believed to have identified and described this condition in 1836, for the first time.  Although the etiopathogenesis is incompletely understood, it is considered as a physiologic condition occurring due to aging.  It is unlikely that palatal ecchymosis is encountered on a day-to-day basis, especially in the elderly. When encountering such a case, it is imperative for all oral diagnosticians to consider the possibility of SP, which is a benign condition.
| Case Report|| |
A 72-year-old female patient visited the outpatient department with the complaint of broken maxillary complete denture of 4 days duration. Her medical and surgical histories were not significant. Patient was apparently healthy and was not under any medications for any systemic illness. History revealed that the dentures had been fabricated 8 years back and that the maxillary denture accidently fell and broke. Citing aesthetic reasons, she continued to wear the unrepaired denture for the past 4 days. On examination of the oral cavity, the maxillary and mandibular completely edentulous arches were evident. The hard palatal mucosa showed bilaterally diffuse linear ecchymosis and purpuric spots, each measuring approximately 2 cm × 0.5 cm in size, more pronounced on the lateral aspects of the palate, corresponding to pressure areas from the denture. Rest of the mucosa was normal. Upon palpation, the area was non-tender and non-blanching [Figure 1]. On questioning the patient about the palatal lesions, she replied that she had neither noticed it nor had any symptoms. A detailed history of bleeding or clotting disorders including family history was elicited, which was found to be negative. There was no history of similar purpuric areas elsewhere on the body nor any history of easy bleeding tendencies of recent onset. There was no history of spontaneous bleeding, easy fatigability, loss of weight or appetite, fever, or recent viral infections. Examination of the extremities showed no evidence of purpura or ecchymosis on the exposed parts. A complete hemogram with peripheral smear showed parameters within normal limits. Patient was mildly anemic with the hemoglobin being 12.6 g%. There was no thrombocytopenia and the clotting factors were within limits. International Normalized Ratio (INR) was 0.9, which was within limits. Liver function tests showed normal values of serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT). Also, a smear examination from the palate for Candida was negative, which ruled out superficial fungal infection.
Based on the above features, the case was diagnosed as SP. The patient was advised to discontinue the use of the fractured denture and was recalled for review after 1 week. The following week, ecchymosis had completely resolved [Figure 2]. Fabrication of new dentures was done, with the operator being cautious and gentle to prevent development of new lesions. Patient was counseled and educated about the condition and the possibility of development of such lesions elsewhere in the body or in the oral cavity. A 1-month follow-up failed to reveal any new lesions.
|Figure 2: One-week follow-up photograph showing clearing of the ecchymosis|
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| Discussion|| |
SP is a benign condition whose pathogenesis is not very well understood. It is considered as a consequence of physiologic aging due to laxity of the connective tissue. Any minor trauma to the blood vessels results in ecchymosis or purpura. Furthermore, it is believed that there is delayed resolution of the ecchymosis due to abnormal macrophage function.  Also, with aging, there is reduction in elastic and collagen fibers with increased susceptibility to external trauma.  Chronic usage of certain drugs like the nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or anticoagulants may predispose to the development of SP in some elderly patients.  Deficiency of zinc  and underlying liver disorders are also postulated in the development of SP.  The case presented here had nomal liver function, was not under medications, and was otherwise healthy.
SP of the skin is rather an uncommon condition. The prevalence is in the range of 1-14% in different populations. ,,, Prevalence of oral manifestations of SP has not been studied so far. No gender difference can be found, , but it exclusively occurs in the elderly and, hence, the name senile purpura.
SP presents as non-palpable purpuric or ecchymotic spots on the extensor surfaces of the arms and feet and are non-tender.  Intraorally, SP presents as ecchymosis commonly occurring on the palate, tongue, and on the lips.  Ecchymosis was noted on the denture-bearing surfaces on the palate and the rest of the oral mucosa was spared in the case described here, who was otherwise healthy. In contrast, the subjects in the previously reported cases had ecchymosis on the palate secondary to prolonged usage of medications along with the use of dentures.  Hence, minor trauma from the ill-fitting dentures resulted in palatal ecchymosis in the present case. Histopathologically, SP shows vascular ectasia with extravasated erythrocytes, with degenerated collagen fibers and no vasculitis. ,
Differential diagnosis includes ecchymosis and purpura due to other causes such as myleodysplastic syndrome, leukemia, qualitative and quantitative platelet disorders, and coagulative disorders.  It is mandatory to perform investigations to rule out any underlying serious medical conditions. Hematologic investigations such as complete hemogram with peripheral smear examination, liver function tests, prothrombin time (PT), activated partial thromboplastin time (aPTT), and INR are performed. In addition, serum zinc estimation can also be done. ,, Essentially, all the parameters will be under limits in SP, just as in the present case.
SP, a common dermatologic condition with no clinical outcome, requires no special management protocol. The patient needs to be reassured about the benign nature of the disease and cautioned about minor trauma as an etiologic factor. Furthermore, careful handling of oral mucosal tissues is of greatest importance in avoiding oral ecchymosis. , In a clinical trial, oral citrus bioflavonoid has been successfully utilized to demonstrate reduced episodes of development of purpura/ecchymosis. 
Precautions for the dental caregiver
Utmost care is to be taken while treating patients with a history of SP, as there is easy bleeding due to minor trauma. The oral tissues are to be handled gently, particularly during fabrication of dentures and adjustment of pressure points, and usage of saliva ejectors or suction tips should be avoided. 
| Conclusion|| |
This case has been successful in depicting the oral manifestations of SP in an elderly subject with no previous history of SP. Hematologic investigations proved to be beneficial in diagnosing this rare condition of oral ecchymosis. Oral manifestations of SP, although rare, should be included in the differential diagnosis along with other serious medical conditions. Furthermore, the importance of gently handling our elderly population, both physically and emotionally, need not be overemphasized.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
da Rosa RS, Garcia RC, Cury AA, Faot F. Management of the oral manifestations of senile purpura in an edentulous patient: A case report. Spec Care Dentist 2011;31:111-3.
Karnath BM. Easy bruising and bleeding in the adult patient: A sign of underlying disease. Hosp Phys 2005;41:35-9.
Fein H, Adams BB. Myelodysplastic syndrome presenting as cutaneous purpura. Cutis 2000;65:367-70.
Haboubi NY, Haboubi NA, Gyde OH, Small NA, Barford AV. Zinc deficiency in senile purpura. J Clin Pathol 1985;38:1189-91.
Nair PA, Bodiwala N, Arora TH, Patel S, Vora R. A study of geriatric dermatosis at a rural hospital in Gujarat. J Indian Acad Geriatr 2013;9:15-9.
Derbes VJ, Chernosky ME. Senile purpura and liver disease: A possible relationship. Arch Dermatol 1959;80:529-32.
Pavithra S, Shukla P, Pai GS. Cutaneous manifestations in senile skin in coastal Goa. Nep J Dermatol Venereal Leprol 2010;9:1-6.
Durai PC, Thappa DM, Kumari R, Malathi M. Aging in elderly: Chronological versus photoaging. Indian J Dermatol 2012;57: 343-52.
Shuster S, Scarborough H. Senile purpura. QJM 1961;30:33-40.
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;10:718-22.
[Figure 1], [Figure 2]