What is the initial approach to managing a patient with Henoch-Schönlein purpura (HSP)?

Initial Management of Henoch-Schönlein Purpura

The initial approach to HSP centers on supportive care with symptom management, immediate urinalysis to assess renal involvement, and risk stratification based on age and organ system involvement, reserving corticosteroids specifically for severe abdominal pain, joint symptoms, or documented nephritis rather than routine prophylactic use. 1

Diagnostic Confirmation

• Establish diagnosis clinically when palpable purpura is present plus at least one of: renal involvement (hematuria/proteinuria), arthralgia/arthritis, or abdominal pain 1, 2
• Obtain urinalysis with microscopy immediately at presentation to assess for glomerulonephritis, looking specifically for proteinuria, red blood cell casts, and dysmorphic red blood cells 1
• Perform basic metabolic panel (BUN, creatinine) and complete blood count with platelets to assess renal function and rule out thrombocytopenia 1
• Measure blood pressure as hypertension indicates more severe renal involvement 1
• Normal urinalysis on day 7 has 97% negative predictive value for normal renal outcome, which guides subsequent monitoring intensity 3

Initial Treatment Strategy

Supportive Care (First-Line for Most Patients)

• Provide supportive treatment as primary intervention since HSP spontaneously resolves in 94% of children and 89% of adults 2
• Use acetaminophen (paracetamol) as first-line analgesic rather than NSAIDs like ketorolac (Toradol), which can cause acute kidney injury especially with pre-existing renal impairment 1
• Provide patient education about natural history, expected course, and warning signs requiring urgent evaluation 1

Corticosteroid Use (Selective Indications)

• Offer oral prednisone 1-2 mg/kg daily for two weeks specifically for severe abdominal pain or significant joint symptoms, not as routine prophylaxis 1, 2
• Do NOT use corticosteroids prophylactically at HSP onset to prevent nephritis—moderate quality evidence (Level 1B) shows no benefit in preventing nephritis or reducing risk of severe persistent nephritis 1
• Meta-analysis evidence shows corticosteroids reduce mean time to resolution of abdominal pain and decrease odds of developing persistent renal disease when used for symptomatic treatment 2

Alternative Therapies for Persistent Symptoms

• Consider colchicine 1 mg/day for at least six months for persistent purpura and pain unresponsive to initial measures 1
• Low-antigen-content (LAC) diet may improve symptoms when strictly followed for 4-8 weeks and can be used in conjunction with other treatments 1

Risk Stratification

• Adults have worse prognosis than children with higher risk of complications and progression to end-stage renal disease 1, 2
• Older patients at higher risk of requiring renal referral (mean age 12.3 years vs. 6.0 years for normal outcome) 3
• Renal involvement is the most likely source of long-term morbidity, occurring in 40-50% of patients 2

Monitoring Protocol

• Monitor all patients for at least 6 months with regular urinalysis for proteinuria/hematuria and blood pressure measurements 1, 4
• Intensify monitoring for patients with abnormal urinalysis on day 7, as they are at higher risk of developing nephritis 3
• Renal ultrasound is preferred initial imaging if renal biopsy is being considered for severe nephritis 1

Management of Renal Involvement

• Start ACE inhibitor or ARB therapy for persistent proteinuria in HSP nephritis, even though evidence is extrapolated from IgA nephropathy 1
• Reserve corticosteroid therapy (6-month course) for persistent proteinuria >1 g/day per 1.73 m² after ACE inhibitor/ARB trial and GFR >50 ml/min per 1.73 m² 1
• Treat crescentic HSP with nephrotic syndrome and/or deteriorating kidney function with high-dose intravenous methylprednisolone plus cyclophosphamide 1

Common Pitfalls to Avoid

• Do not start corticosteroids too early for mild proteinuria without adequate trial of ACE inhibitor/ARB therapy 1
• Avoid NSAIDs (including ketorolac/Toradol) in patients with any renal involvement due to risk of acute kidney injury 1
• Do not attempt to normalize proteinuria to <0.5 g/day/1.73 m², which increases side effects without proven benefit; target <1 g/day/1.73 m² instead 1

Long-Term Considerations

• End-stage renal disease occurs in 1-5% of patients, with prognosis depending on severity of renal involvement 2
• Women with childhood HSP history are at increased risk of proteinuria and hypertension during pregnancy and require close monitoring 4