Hemorrhagic rash is a noninflammatory rash by the type of stain (primary rash infiltrative element of the rash). Hemorrhagic rash is usually localized at the level of the epidermis and / or in the papillary dermis. It is formed as a result of damage of the vascular wall with an infectious agent or immune complexes, for this reason, the blood vessels leave the blood vessels. When pressing such a rash does not disappear and its color does not change in any way. It is, like all spots, at the level of the skin, not towering over it.
Depending on the size of the elements of hemorrhagic rash, several types can be distinguished: petechiae - point elements; purple - up to one centimeter; ecchymosis (bruise) - more than three millimeters. Hemorrhagic rash is provoked by such diseases as meningococcemia, hemorrhagic vasculitis, scarlet fever and others.
Causes of hemorrhagic rash
A rash of a hemorrhagic nature is not so rare, its causes are a variety of diseases of an infectious or immunocomplex genesis.
In the emergence of hemorrhagic rash of immunocomplex genesis, the interaction between the antigen and the antibody plays the leading role, which leads to the formation of circulating immune complexes. Causes of the formation of the CEC can be burns, vaccinations, viruses, bacteria, hypothermia, medicines, etc. An example of a disease accompanied by a hemorrhagic rash of this origin is hemorrhagic vasculitis .
Formed CEC "storm" the endothelium of small vessels. After such exposure, aseptic inflammation develops in the vessel wall, i.e. inflammation of non-infectious origin. To fight the CEC, the body directs leukocytes that release free radicals of oxygen; macrophages brought into the active state; lysosomal enzymes; interleukins six and eight. All these activated factors cause damage to the vascular wall with the formation of necrosis and swelling around the vessels.
Damage to the vascular wall activates the hemostasis system. The system of hemostasis activates the adhesion of platelets, hypercoagulation, an increase in von Willebrand factor (its synthesis occurs mainly in the wall of the vessels, therefore it reflects the severity of endothelial damage). All this leads to the release of blood cells from the bloodstream, the formation of microthrombi and skin hemorrhagic rash - this is the result of the catastrophe occurring in the body.
With the development of hemorrhagic rash of infectious genesis, the pathogenetic picture is somewhat different.
In infectious diseases, for example, in the generalized form of meningitis (meningococcemia), a hemorrhagic rash on the skin appears due to the action of toxins of the causative agent on the capillaries, which disturbs the peripheral hemodynamics. Hypercoagulation develops, elements of hemorrhagic rash appear on the skin.
And in the first and second cases, hemorrhagic rash develops not only on the skin, similar changes occur in the internal organs, which complements the picture of hemorrhagic rash in this or that disease.
Symptoms of hemorrhagic rash
Hemorrhagic skin rash, as a rule, is not a single symptom of the disease. In addition, the rash of hemorrhagic character with different diseases is not the same, has its own specific characteristics only for a particular disease.
So, with the local form of hemosiderosis, hemorrhagic eruptions are formed by the type of hematoma, which subsequently acquire a rusty color. This color is formed as a result of extravascular rupture of erythrocytes with the release of iron-containing hemosiderin pigment from them. It hemosiderin and gives the skin hemorrhagic rash a "rusty" color.
A similar process occurs not only at the skin level, but also in organs that we do not see with the eye (liver, lungs, spleen), disrupting their work. Internal organs, like skin, acquire a "rusty" color.
There is a hemorrhagic rash on the skin and with various diseases of the hepatobiliary system. But in this case the hemorrhagic rash is usually accompanied by a skin itch because the liver ceases to cope with the processing of toxins.
In liver diseases, such as liver cirrhosis , viral hepatitis, there is a small hemorrhagic rash, which is part of the hemorrhagic syndrome. Its formation is associated with a violation of the most important functions of the liver - the formation of coagulation factors, in particular, the synthesis of prothrombin.
Hemorrhagic rash with hepatitis is small, localized on the face, trunk, neck, less often on the limbs.
In addition to hemorrhagic rash, liver diseases develop vascular sprouts ( telangiectasia ), these are dilated capillaries that are localized on the upper part of the human body. The principal difference between vascular asterisks and hemorrhagic rash is that when the skin is depressed or stretched, the telangiectasia disappears, but after the cessation of the effect again appear. This is explained by the fact that when exposed to the skin, the filling of capillaries with blood decreases, and after the pressure ceases, the blood again returns to the expanded capillaries.
There is a hemorrhagic rash with such a serious disease as Wegener's granulomatosis. The cause of the disease is an autoimmune process that causes generalized vasculitis, affecting mainly the lungs, kidneys, heart, eyes. Other organs are damaged less often. Skin manifestations of this disease can be observed in the form of a small hemorrhagic rash on the limbs.
Types of hemorrhagic rash
Primary and secondary elements - this is the general subdivision of the elements of the rash. A spot, a kind of hemorrhagic rash, refers to primary elements, or rather, appearing on unaltered skin. Secondary elements are considered as evolutionary changes of primary elements.
The primary elements are divided into cavitary and inferior. Spot - the main element of hemorrhagic rash, belongs to the category of the latter. Hemorrhagic rash belongs to the category of non-inflammatory spots. From inflammatory differs in that when pressing on the elements of hemorrhagic rashes do not disappear. Inflammatory, on the contrary, disappear, but then appear again. develop as a result of the expansion of the vessels of the dermal layer of the skin.
The diameter of the elements hemorrhagic rash is divided into the following types: petechiae, ecchymosis and purpura. Petechia is a small hemorrhagic rash the size of a point. Purple is slightly larger, it is round in shape and in diameter reaches 2-5 mm. The largest elements in the discharge of hemorrhagic rash are ecchymoses. They are irregular in shape and reach a size of more than 5 mm.
Elements of hemorrhagic rash can merge with each other. Such areas have a purple-cyanotic color, often with necrotic infection in the center. Sometimes, with a particularly turbulent and severe development of the pathological process, necrotization from the center extends to the periphery with the rejection of significant areas of the skin. In such dangerous situations, a gangrenous change in the surface of the skin develops.
Any hemorrhagic rash is a consequence of increased vascular wall porosity or a violation of its integrity, which is provoked by toxins, traumas, metabolic disorders, inflammatory agents in various diseases.
Hemorrhagic rash in children
In children, hemorrhagic rash often accompanies such diseases as hemorrhagic vasculitis (Scheinlein-Henoch disease), thrombocytopenic purpura , hemophilia , meningococcemia. With hemorrhagic vasculitis, it is included in the concept of skin syndrome. This is a kind of "visiting card" of the disease. A typical manifestation of hemorrhagic vasculitis is a hemorrhagic rash on the legs, more precisely, on the anterior surface of the shins, in the periparticular region of the knee and ankle joints. It can also be localized on the skin of the thighs, buttocks, around the elbow joints and the trunk. But more often, nevertheless, there is a hemorrhagic rash on the legs.
The elements of the rash are symmetrical, they are the same in appearance, they do not bloom, they do not disappear when they are pressed. After the resolution of the disease, pigmentation often remains in place of the elements of the hemorrhagic rash. In severe hemorrhagic vasculitis, the elements of cutaneous hemorrhagic rash can merge, forming ulcerative necrotic areas. Most often with vasculitis, hemorrhagic rash on the skin is the first manifestation of the disease and only in a small number of patients, vasculitis manifests with abdominal or joint syndrome.
In the generalized form of meningitis meningogoccecemia, hemorrhagic rash is one of the characteristic symptoms of the disease. The disease begins suddenly with a fever of 39 to 40 degrees, a headache, and vomiting is possible. Stellate hemorrhagic rash appears on the second day of the disease. Elements of purple-red color with a bluish tinge, of various diameters. The diameter varies from petechiae to ecchymosis. Palpatory elements dense, slightly rise above the level of the skin, irregular stellate shape. First arise on the legs, more precisely, on the hips, buttocks, legs, heels. In the center of large elements, necrosis can be formed, up to the development of gangrene.
Stellate hemorrhagic rash requires emergency hospitalization. always talks about the generalization of the process. Not all elements of the rash can be seen with the eyes, some of them can be located on the internal organs. The formation of elements of hemorrhagic rash in adrenal tissue is the most dangerous.
If a skin hemorrhagic rash appears on the face in the early stages of the disease, it is considered an unfavorable sign for the further course of the disease.
With a favorable course of the disease, the hemorrhagic rash is extinguished with the formation of pigmentation. With mild degree of extinction occurs in 1-3 days, with moderate severity, the elements persist for up to seven days, in severe cases, stellate hemorrhagic rash can persist for two to eight weeks.
Hemorrhagic rash with thrombocytopenic purpura is associated with platelet deficiency. Features of the elements of hemorrhagic rash in this disease is that the rash is blooming. With the passage of time, the color changes and it is always possible to determine which elements appeared earlier, and which ones later; the elements are polymorphic, ie, of different sizes from petechiae to ecchymoses; located asymmetrically and spontaneously arise for no apparent reason. Elements of hemorrhagic rash are located on the trunk, limbs, face, rarely on the scalp. The number of elements can be so great that the skin looks like a leopard skin.
Thrombocytopenic purpura is manifested not only by hemorrhagic rash, but also by hemorrhages, more often by nasal, which are difficult to stop by conventional methods.
Treatment of hemorrhagic rash
Treatment of hemorrhagic rash is aimed at treating the underlying disease, of which it is a symptom.
Treatment of Wegener's granulomatosis consists in the use of cytotoxic drugs in combination with glucocorticosteroid preparations. Isolated use of the latter has shown ineffectiveness in the fight against the disease. The main cytotoxic drug for the treatment of this disease is Cyclophosphamide, Methotrexate and Chlorbutin are considered as alternative drugs when Cyclophosphamide can not be used.
Cyclophosphamide is combined with Prednisolone. When remission is achieved, drugs are gradually phased out. With adequate treatment, remission can last up to 15 years.
Treatment of hemosiderosis consists in the use of drugs from the group of immunosuppressants, but the results of treatment are not always satisfactory. The use of immunosuppressants is combined with the conduct of plasmapheresis. Symptomatic treatment with the appointment of iron preparations for replenishment of its stocks in the blood is also performed. For better absorption of iron preparations, together with them, it is recommended to take ascorbic acid. In addition to the main treatment, vitamin and mineral complexes are prescribed.
The main method of treating Sheinlein-Henoch disease is the appointment of anticoagulants (Heparin) and disaggregants (Curantil, Trental, Ticlopidine, Plavix) to combat increased thrombus formation. To the appointment of Heparin, there are separate indications, this is abdominal and renal syndrome, a discharge hemorrhagic rash, especially with a ulcerative-necrotic component. If Heparin is prescribed, then it is necessary to monitor the results of its action in the body in laboratory, a blood test for APTT and paracoagulation tests is done.
Glucocorticosteroids may also be prescribed for certain indications: with persistent recurrent disease, nephrotic syndrome, complicated course of hemorrhagic vasculitis.
Treatment of any form of hemorrhagic vasculitis should be performed in a hospital. A set of drugs for treatment should be strictly limited, because Any auxiliaries can only increase the course of the disease. The patient's diet should also be adjusted, eliminating allergen products: coffee, chocolate, citrus fruits, etc.
Treatment of thrombocytopenic purpura should also be complex, plus a hypoallergenic diet. The main group of drugs for treatment are glucocorticosteroids, which are prescribed in all cases (the basic drug is Prednisolone). They inhibit the destruction of platelets in the spleen, improve their properties, have an immunosuppressive effect.
Assigns also immunoglobulin G intravenously and anti-D-immunoglobulin.
In exceptional cases, surgical removal of the spleen is indicated. At present, it is rarely resorted to.
Treatment of hemorrhagic rash with meningitis infection is carried out with the appointment of antibiotics to which meningococcus is sensitive. Treatment is carried out only in a hospital. Children who have been in contact with a patient with a generalized form of meningitis need to introduce a prophylactic immunoglobulin to prevent the development of infection.
When a stellate hemorrhagic rash is found on the patient's skin, delaying hospitalization is unacceptable. Patients are hospitalized by the resuscitation team.