A generalized case of purpura annularis telangiectoides of Majocchi

Pigmented purpuric dermatoses (PPD) are a group of chronic, progressive vascular disorders which are resistant to treatment [1]. Purpura annularis telangiectoides (PAT) is an uncommon PPD which is also known as Majocchi disease [2,3]. It is usually seen in adolescents and young adults and characterized by non-palpable annular patches on the lower extremities2. Herein we present an atypical case of generalized PAT in an elderly woman patient.


INTRODUCTION
Pigmented purpuric dermatoses (PPD) are a group of chronic, progressive vascular disorders which are resistant to treatment [1].Purpura annularis telangiectoides (PAT) is an uncommon PPD which is also known as Majocchi disease [2,3].It is usually seen in adolescents and young adults and characterized by non-palpable annular patches on the lower extremities 2 .Herein we present an atypical case of generalized PAT in an elderly woman patient.

CASE REPORT
An 88-year old women presented with a pruritic eruption which had started 5 months ago.She had hypertention and congestive heart failure and had been using acetylsalycilic acid, metoprolol and losartan potassium therapies for 10 years.Her past medical story was otherwise nonspecific.Dermatological examination revealed multiple red-brown annular patches with central clearing on both of the extremities and trunk (Figs 1 and 2).Laboratory examinations including complete blood count, routine biochemistry, coagulation parameters, urinanalysis were normal.
Punch biopsy from the lesions showed perivascular lymphocyte infiltration in the papillary dermis and extravasated red blood cells (Fig 3).The patient was diagnosed as PAT and treatment with topical corticosteroid and antihistaminic was started, the lesions showed moderate regression after 15 days.The patient's informed consent was obtained.Prior to the study, patient gave written consent to the examination and biopsy after having been informed about the procedure.
PAT is a rare form of PPD which was first described in 1896 by Domenico Majocchi [2].It is usually observed in female adolescents symetrically on the lower extremities [5].Punctate telangiectatic and purpuric macules progress to annular patches with central clearing and infrequently atrophy [2,4,6].The lesions are mostly annular but stellate, serpiginous and linear forms have been described [5].Pruritus is usually not observed [2].
Though there is no medication of proven benefit, topical and oral corticosteroids, antihistamines, pentoxyphylline, psoralen-ultraviolet-A and narrowband ultraviolet-B have been used in the treatment [1,3,5].
We presented our case as generalized lesions in an elderly women is a very rare and atypical presentation of PAT.We would like to remind that the differential diagnosis of PAT should be considered in patients with annular erythematous eruptions.

1) Purpura annularis telangiectoides (PAT) can present
with generalized lesions 2) The differential diagnosis of PAT should be considered in patients with generalized annular erythematous eruptions 3) PAT can be observed in elderly women

CONSENT
The examination of the patient was conducted according to the Declaration of Helsinki principles.

Figure 2 :
Figure 2: Annular patches with cenral clearing on the lower extremities.