It is not uncommon for children to experience skin complaints in the form of a rash or reddish patch that does not itch on the skin. These skin disorders are called purpura and petechiae. What is the danger when children have purpura or petechiae on their skin? And how to evaluate and treat petechiae and purpura in children? This article discusses purpura and petechiae in children.


Overview of Purpura and Petechiae

What are purpura and petekie?

Purpura and petechiae are bleeding small blood vessels in the skin and mucosa. Purpura is larger than 2mm, whereas petechiae are smaller (1–2 mm). Purpura and petechiae are not a diagnosis but are signs or clinical manifestations of various conditions or diseases. 

Purpura on leg of child with HSP
Purpura on the left leg of a Child with HSP



Purpura and petechiae can be mild, such as those caused by mechanical causes. But they can be more serious, such as those caused by invasive meningococcal disease (IMD) or immune thrombocytopenic purpura (ITP). The characteristics of purpura and petechiae and their accompanying symptoms need to be recognized to prevent further complications. Thus, the clinician must be able to evaluate purpura and petechiae with various underlying conditions

Petechiae In Children
Petechiae on leg skin
image source: ttps://pdfs.semanticscholar.org


How can purpura and petechiae appear?

The pathogenesis of purpura is the extravasation of erythrocytes from blood vessels on the skin or mucosal surfaces. In contrast, Petechiae appears due to trauma to the capillaries, inflammation of the capillary walls, or low platelet levels.


How to distinguish purpura and petechiae from others rash?

The way to distinguish purpura or petechiae from other rash is to apply pressure to the skin lesion with a transparent glass or object. In petechiae and purpura, the spot will not disappear when applying pressure.


What are the causes of Purpura and Petechiae?

The causes of purpura and petechiae can vary, including:
  • Mechanical causes: A history of direct trauma or vomiting and coughing can give children the symptoms of petechiae or purpura
  • Infections: dengue fever, invasive meningococcal disease (IMD), scarlet fever, and other viral infections
  • Hematological disorders and malignancies: leukemia, immune thrombocytopenic purpura (ITP), neuroblastoma, disseminated intravascular coagulation (DIC), hemolytic uraemic syndrome (HUS)
  • Vasculitis and inflammatory reactions: Henoch-Schönlein purpura (HSP)
Purpura that occurs due to serious diseases, such as invasive meningococcal disease and other bacterial infections, can be found in 10% of cases, so clinicians must identify it precisely. Other diseases such as Henoch-Schönlein purpura, idiopathic thrombocytopenic purpura, acute leukemia, and HUS can also underlie these lesions' appearance. Complementary symptoms and investigations can guide the clinician to determine the cause of purpura in children.


Evaluating Purpura and Petechiae in Children

The first step of evaluating purpura and petechiae in children is to assess the child's general condition, whether the child looks sick or healthy. A visibly ill child with purpuric manifestations should be assumed to have a serious disease before any other diagnosis is confirmed.


a. Accompanying Symptoms and Signs

Doctors must actively look for other symptoms and signs to recognize and rule out serious disorders in children. Symptoms and signs that must be observed in children with purpura or petechiae are:

Fever:
Fever is an important symptom in evaluating children with purpura or petechiae. In IMD, generally, the child will look sick and have a fever. However, IMD's diagnosis cannot be ruled out if fever is not found at the initial assessment.

b. Characteristics of Purpura and Petechiae Lesions

An initial evaluation in children with petechiae and purpura signs must be performed quickly and precisely to determine further management. In cases where IMD is suspected, early diagnosis and management can prevent complications and provide a better clinical outcome.

Purpuric or petechial lesions, which are limited to the superior vena cava distribution, are generally caused by increased venous and capillary pressure from coughing, vomiting, and crying. Most of the children are in good condition and do not experience  IMD.

In tropical countries, fever accompanied by petechiae or purpura needs to be watched out for as a symptom of dengue virus infection. Most dengue fever patients (71.28%) had mucocutaneous symptoms, and petechial lesions were found in 41.23% of patients. Although viral infection in children often presents as symptoms of erythema lesions, doctors need to recognize these features to prevent more severe abnormalities.


c. Laboratory examinations

Laboratory tests need to be done to determine the cause of purpura in children. Tests that include complete blood counts with platelet counts, peripheral blood smears, as well as prothrombin time (PT) and activated partial thromboplastin time (aPTT) can be performed as indicated.

Abnormal results, such as leukocytosis or elevated C-reactive protein, indicate the need to prompt antibiotics and hospitalization.

If the platelet count is low without any other abnormalities on the complete blood count, the diagnosis is more towards immune thrombocytopenic purpura (ITP). Anemia with thrombocytopenia may indicate leukemia, systemic lupus erythematosus, or aplastic anemia.


Causes of Purpura and Petechiae in Children

If emergency signs and symptoms in children are not found or have been resolved, consider other possible causes of petechial or purpuric lesions. Several conditions can cause purpura and petechiae, including:

a. Infectious Diseases

Infectious disease (bacteria or viruses) can cause purpura in children. Bacterial infections with purpuric manifestations are invasive meningococcal disease (IMD) and scarlet fever. Viral infections with purpuric manifestations are dengue fever, parvovirus, and enterovirus.

b. Mechanical or trauma causes

Petechiae and purpura can also be caused by physical trauma to the capillaries. A history of trauma can characterize this situation before the appearance of petechiae.

c. Immune Thrombocytopenic Purpura (ITP)

In ITP, the general condition of the child is usually good. Petechiae may be accompanied by multiple bruised lesions that appear in acute onset. A viral infection may precede ITP lesions, either asymptomatic or accompanied by fever and mucocutaneous bleeding symptoms. ITP in children generally lasts less than six months and can resolve spontaneously.

Complete peripheral blood observation can be done to monitor the course of the disease. Additionally, patients need to avoid activities or sports that require body contact, such as soccer.

d. Henoch Schonlein Purpura (HSP)

In HSP, lesions of palpable purpura, bruises, and urticaria can appear at the site of predilection, namely the extensor lower extremities. Purpura can be accompanied by joint pain and abdominal pain. In patients with HSP, observation is needed to assess renal involvement. Blood tests can be done by evaluating urea and electrolyte levels.

e. Coagulopathy

Coagulation disorders due to disorders of the primary clotting factors (platelets and blood vessels) can provide a picture of bruising, petechiae, and bleeding in the mucosa.

f. Acute Leukemia

Purpura in acute leukemia usually presents a slower onset and is accompanied by anemia, lymphadenopathy, or hepatosplenomegaly.

g. Hemolytic-Uremic Syndrome (HUS)

In children with HUS, oliguria/anuria is usually associated with anemia and accompanied by diarrhea.



Investigations for Purpura in Children

Investigations in children with purpura need to be performed to find out the cause and rule out a possible IMD diagnosis.

If the history and physical examination suggest a bleeding disorder, laboratory tests should include complete blood counts, peripheral blood smears, and coagulation function (PT and aPTT). These tests can generally identify hemostatic abnormalities.

If the suspicion suggests IMD or other infection: C-reactive protein levels and blood cultures should be performed. It is necessary to consider examining blood gases and blood glucose levels in children who are lethargic and irritable.

In HSP, urinalysis can be done to see if the kidneys are involved. Whereas in trauma, a clear history of trauma is generally found so that no investigation is required.


Management

The management of purpura and petechiae in children is adjusted according to the underlying disease. In children with fever or a history of fever accompanied by petechial or purpuric lesions, the doctor should suspect a serious IMD infection.

In suspected IMD cases, early administration of antibiotics is of utmost importance to produce a good clinical outcome. The importance of diagnosis and hospitalization is secondary and not more important than the administration of antibiotics.

The administration of supportive therapy and corticosteroids has shown benefit in the purpuric cases seen in HSP.


Conclusion

Skin lesions in the form of purpura and petechiae are common in children. The causes of these skin lesions can vary, from physical trauma to the capillaries to life-threatening conditions, such as invasive meningococcal disease (IMD).

The first step that needs to be taken to evaluate purpura in children is to assess the child's general condition. The invasive meningococcal disease needs to be considered in children who appear sick and feverish before a definite diagnosis is made.

Purpura with fever indicates bacterial infections (such as invasive meningococcal disease and scarlet fever) and viruses (such as dengue fever, parvovirus, and enterovirus). Complete blood count, platelet counts, and C-reactive protein can distinguish the two causes.

The most common cause of purpura in children is immune thrombocytopenic purpura (ITP). This disorder's characteristic is that the child appears healthy with a sudden onset of bruises (purpura and petechiae) and usually resolves spontaneously. A low platelet count can confirm this disorder.

The suspicion of a coagulation disorder can be confirmed by examining the coagulation factor. Chronic-onset purpura with anemia, thrombocytopenia, or organomegaly may suggest leukemia, systemic lupus erythematosus, or aplastic anemia.