Actinic purpura presents as patches and macules with irregular edges on the forearm and back of the hands. However, they can affect other areas, such as legs, neck, and face. The lesions may appear as dark purple macules and extensive ecchymosis, with average sizes ranging from 1cm to 4 cm in diameter. These macules are asymptomatic and are not associated with pruritus or tenderness. The surrounding skin is generally of an altered quality (thin, pigmented and inelastic).  Besides the typical presentation of actinic purpura, there may be evidence of other photo-aging lesions such as wrinkling, lentigines, sallow yellow skin hue, and actinic keratosis and stellate pseudo scars.[8]

The purpuric lesions persist for about one to three weeks before resolving spontaneously. However, they do not undergo the phases of inflammation. It is possible that a residual deposit of hemosiderin in the dermis leaves a brown pigmentation. Actinic purpura, however, can continue to occur because of the already established cutaneous and vascular fragility. The ecchymotic lesions can cause a significant aesthetic problem and have a psychological impact, however, there is no risk of serious complications.[3]

The diagnosis of actinic purpura is usually clinical and based on history and physical examination. In the rare cases where a biopsy is performed, the histological study will show a thinned epidermis ascending on an altered dermis with quantitatively reduced collagen fibers and abnormal elastic fibers. The walls of the dermal vessels have a normal tensile structure, but there is extravasation of red blood cells and hemosiderin deposits marked by Perl’s staining. In about 10% of cases, there is a neutrophilic infiltration that may lead to the misdiagnosis of actinic purpura as neutrophilic dermatosis or leukocytoclastic vasculitis.[9]

Coagulation analysis is rarely necessary and usually shows no abnormalities.

Actinic purpura is a benign condition that does not require specific treatment, particularly since other lesions continue to appear throughout life. The best treatment is preventive and involves protection from excessive sun exposure through the application of sunscreen and wearing long-sleeved shirts. One should apply sunscreens with a high protection index (sun protection factor (SPF) greater than 50) daily to provide sufficient protection against the ultraviolet (UVB and UVA) rays. The sunscreen should be liberally applied to all sun-exposed areas regularly.[10][11]

The therapeutic possibilities available for the actinic purpura lesions already formed are restricted. Tretinoin or retinoic acid (0.1%) is a derivative of vitamin A, which could theoretically reverse severe skin damage induced by ultraviolet light. Indeed, topical tretinoin is known for its role in the regeneration of dermal collagen and the reduction of the quality of abnormal elastin damaged by solar exposure. However, some authors demonstrate that the developed plaques of actinic purpura do not improve under local treatment with tretinoin.[3][1] 

In 2002, actinic purpura was successfully treated in one patient with tissue-engineered skin; however, no similar cases have been reported. More recently, it has been demonstrated that the human epidermal growth factor may be a viable treatment of actinic purpura. It has been shown to increase the average skin thickness and reduce the number of purpuric lesions when applied twice daily for six weeks. A citrus bioflavonoid blend has been tested for the treatment of actinic purpura. After six weeks, the treated group showed a 50% decrease in purpuric plaques with no reported side effects. Laser therapy, which is widely used for the treatment of aging skin manifestations, is not indicated in actinic purpura. Moisturizing creams may be useful to treat associated skin xerosis.[8]

The differential diagnosis of Actinic purpura would be:[12]

• Steroid-induced Purpura
• Physical trauma
• Use of Anticoagulants
• Scurvy, Vitamin C deficiency
• Vitamin K deficiency
• Psychogenic purpura
• Palpable purpura (hemorrhage and inflammation)
• Primary systemic Amyloidosis 

The disease has a good prognosis with a benign course. Typically, the lesions continue to occur throughout life, but they usually resolve in 1 to 3 weeks. It may leave post-inflammatory hyperpigmentation or sometimes scarring, but they are not associated with any other major complication.

It is a benign condition and usually resolves in 1 to 3 weeks with residual pigmentation or sometimes scarring. These lesions can trigger the patient’s emotional distress due to cosmetic disfigurement.[3]

Actinic purpura is a common, benign disease of elderly individuals with fair skin types. The disorder appears to be caused by dermal and vascular fragility induced by chronic sun exposure. It does not predispose to serious complications, and the risk of bleeding is minimal. However, it can cause significant aesthetic and cosmetic damage and can induce a significant psychological impact. Treatment is limited, mainly relying on creams based vitamin A derivatives and moisturizers.

Photoprotection remains the best option, and it is based on physical protective clothing, regular application of sunscreen, and behavioral therapies by avoiding excessive sun exposure and trauma.[13]

An interprofessional approach to actinic purpura is needed. Actinic purpura is a very common condition, especially in elderly individuals. Although the condition is benign, the skin is easily prone to bleeding, even with minor trauma. Healthcare workers, including nurse practitioners, can play a key role in the prevention of this condition. Patients should be encouraged to keep their skin moisturized, use sunscreen, wear sun-protective garments, including a wide-brimmed hat, and try to avoid direct sun exposure and trauma. It should also be noted that patients with actinic purpura are also more prone to develop actinic keratosis, hence proper awareness and a biopsy may be required.[10][13]