Pigmented purpuric dermatosis-ecchymosis and chronic venous disease.

Dear Editor, We have recently read the article published by Parsi et al. with great enthusiasm and curiosity. They have investigated the etiology of pigmented purpuric dermotoses (PPD) in lower extremity of 67 patients. Briefly the authors have assessed the association of PPD with other concurrent conditions such as bleeding diathesis, NSAID and aspirin use, chronic venous disease (CVD), and fish oil use. Eventually, they have documented that CVD has the highest rate of co-existence (76.2%) with PPD. Moreover, complete resolution of PPDs has been achieved in 95% of the treated patients. Ecchymosis, often used interchangeably with purpura, defines the larger area of discoloration of the skin due to extravasations of blood into the subcutaneous tissue. Although they have similar characteristics in terms of erythrocyte extravasations and sequential discoloration of skin due to hemoglobin catabolism, ecchymosis has been reserved for larger and more extensive area of involvement. Within this context association of CVD with PPD or ecchymosis has already been reported in literature. Ecchymosis has been found to be a sign of varicose vein in a cohort of 494 patients in which arterio occlusive disease, anti-platelet and anticoagulation use, trauma and hematologic diseases have been excluded. Moreover, significant association of muscle cramps with ecchymosis has been documented in patients with peripheral varicose veins. Ruptured superficial veins triggered by muscle contraction and subsequent extravasations of erythrocytes have been supposed to be the underlying mechanism of ecchymosis. Likewise, an independent association of ecchymosis with peripheral varicose vein has been confirmed by using the VEINES-Sym questionnaire. In this regard, Parsi et al. has corroborated that pigmented purpuric lesions or ecchymosis of lower extremities might be a sign of peripheral varicose vein. Therefore, in the absence of known hematologic disease, anti-platelet and/or anticoagulant use, presence of peripheral varicose veins should be preferentially considered in differential diagnosis of PPD or ecchymosis. Moreover, careful individual assessment of patients focusing on the presence of peripheral varicose vein and/or CVD might prevent further unnecessary diagnostic measurements for the etiology of ecchymosis.