Blanching vs Non-Blanching Purpura: Management Approach
Non-blanching purpura requires urgent evaluation for life-threatening conditions like meningococcal disease and should be managed based on clinical presentation, distribution pattern, and associated symptoms.
Key Distinctions
Blanching vs Non-Blanching
- Blanching purpura: Reddish lesions that temporarily disappear when pressure is applied
- Non-blanching purpura: Hemorrhagic lesions that do not blanch with pressure, indicating extravasation of blood into tissues
Clinical Assessment of Non-Blanching Purpura
Distribution Patterns
- Dependent distribution: Often associated with leukocytoclastic vasculitis (IgA vasculitis/Henoch-Schönlein purpura)
- Acral distribution: Concerning for microvascular occlusion with high mortality (≈50%) 1
- Superior vena cava distribution only: Less likely to be meningococcal disease 2
- Generalized distribution: May indicate systemic disease
Morphology
- Non-branching (round): Often associated with leukocytoclastic vasculitis
- Branching (retiform): >90% sensitivity and specificity for microvascular occlusion 1
Associated Symptoms
- Fever >38.5°C: Strongly associated with meningococcal disease 2
- Ill appearance: Key indicator of meningococcal infection
- Delayed capillary refill (>2 seconds): Suggests meningococcal disease 2
- Mucous membrane involvement: Consider Stevens-Johnson syndrome/toxic epidermal necrolysis 3
Management Algorithm for Non-Blanching Purpura
Step 1: Assess for Life-Threatening Conditions
Meningococcal disease suspicion (ill-appearing, fever, purpura, delayed capillary refill):
Stevens-Johnson syndrome/TEN suspicion (mucous membrane involvement, skin sloughing):
- Discontinue suspected causative agents
- Immediate dermatology consultation
- Consider admission to burn unit/ICU
- Administer IV methylprednisolone 0.5-1 mg/kg 3
Step 2: Diagnostic Workup
- Complete blood count with differential
- C-reactive protein (CRP) - note that no child with CRP <6 mg/L had meningococcal infection 2
- Coagulation studies (INR)
- Blood cultures if febrile
- Skin biopsy for histopathology to distinguish:
- Leukocytoclastic vasculitis (superficial vs. deep)
- Microvascular occlusion
Step 3: Management Based on Diagnosis
Meningococcal Disease
- Immediate IV antibiotics
- Intensive supportive care
- Monitor for shock, DIC, and multiorgan failure
Leukocytoclastic Vasculitis/IgA Vasculitis (Henoch-Schönlein Purpura)
- Monitor for systemic involvement (renal, GI, joint)
- Supportive care for skin manifestations
- Consider steroids for severe cases with organ involvement 4
Purpura Fulminans
- Immediate protein C replacement therapy (first-line treatment)
- Combined therapy with anticoagulation plus protein C replacement is superior to anticoagulation alone 5
- Consider fresh frozen plasma if protein C concentrate unavailable
Immune Checkpoint Inhibitor-Related Purpura
- Hold immunotherapy
- Dermatology consultation
- Topical emollients and high-strength corticosteroids
- Systemic steroids for severe cases 3
Special Considerations
Pediatric Patients
- Children with non-blanching rash confined to superior vena cava distribution are unlikely to have meningococcal disease 2
- Lack of fever does not exclude meningococcal disease - 5 children with confirmed infection had temperatures <37.5°C 2
Immune Thrombocytopenic Purpura (ITP)
- Children with platelet counts >30,000/μL who are asymptomatic or have minor purpura do not require hospitalization or routine treatment 3
- Children with platelet counts <20,000/μL and significant mucous membrane bleeding should be treated with IVIg or glucocorticoids 3
Caution
- Branching (retiform) purpura, especially in acral distribution, carries high mortality and requires urgent evaluation 1
- Non-blanching petechial or purpuric rash is a high-risk feature requiring immediate evaluation for sepsis 3
- Absence of fever does not rule out serious infection in patients with non-blanching purpura 2