Diagnosis and Management of Fulminant Purpura and Retiform Purpura

Clinical Assessment and Diagnosis

The British Journal of Dermatology recommends documenting the date when the rash first appeared and progression of the eruption in patients with fulminant purpura or retiform purpura 1
A thorough examination of all skin surfaces is necessary to identify target lesions, purpuric macules, blisters, and areas of epidermal detachment, as suggested by the British Journal of Dermatology 1, 3
The extent of erythema and epidermal detachment should be recorded separately on a body map, estimating percentage of body surface area involved, according to the British Journal of Dermatology 1, 3
Mucosal sites (eyes, mouth, nose, genitalia) should be examined for mucositis, blisters, and erosions, as recommended by the British Journal of Dermatology 1, 4
The Journal of Infection suggests assessing for signs of systemic involvement, including respiratory symptoms, gastrointestinal symptoms, and neurological symptoms 1, 2

Fulminant purpura and retiform purpura can be caused by meningococcal sepsis, characterized by rapid progression, purpuric rash, and shock, as stated in the Journal of Infection 2
Drug reactions, particularly Stevens-Johnson syndrome/toxic epidermal necrolysis, can also cause fulminant purpura and retiform purpura, according to the British Journal of Dermatology 1, 4
Rickettsial diseases can present with maculopapular rash with central petechiae, as reported in MMWR Recommendations and Reports 5, 6
Warfarin-induced skin necrosis can occur 3-8 days after initiation of therapy, as described in Chest 7, 8
Immune checkpoint inhibitor-induced severe cutaneous adverse reactions can also cause fulminant purpura and retiform purpura, as stated in the Journal of Clinical Oncology 9

The British Journal of Dermatology recommends immediate discontinuation of any potential culprit drug causing the reaction, and prompt initiation of supportive care with consideration of specific treatments based on etiology 1, 3
For meningococcal disease, the Journal of Infection suggests administering antibiotics immediately, such as benzylpenicillin 1200 mg IV/IM or ceftriaxone 2g IV/IM 2
The Journal of Clinical Oncology recommends admitting patients with severe drug-induced cases to a burn unit or ICU, and applying topical emollients, petrolatum-based products, and high-strength topical corticosteroids 9
For warfarin-induced skin necrosis, Chest suggests discontinuing warfarin therapy, and administering vitamin K and prothrombin complex concentrates to reverse anticoagulation 7, 8

The British Journal of Dermatology recommends maintaining adequate hydration and nutrition, and providing appropriate wound care to prevent secondary infections 1
The Journal of Clinical Oncology suggests considering pain management consultation for adequate analgesia 9

The British Journal of Dermatology recommends performing frequent reassessment of skin lesions, and documenting progression 1, 3
Serial clinical photography can be used to monitor changes, as suggested by the Journal of Clinical Oncology 9
Vital signs and oxygen saturation should be monitored regularly, according to the British Journal of Dermatology and the Journal of Infection 1, 2

Delaying antibiotic administration in suspected meningococcal disease can increase mortality, as stated in the Journal of Infection and MMWR Recommendations and Reports 2, 5
Failing to recognize early signs of shock in infectious purpura fulminans can lead to poor outcomes, as suggested by the Journal of Infection 2
Continuing potential culprit drugs in drug-induced cases can worsen the condition, according to the British Journal of Dermatology 1, 3
Misdiagnosing SJS/TEN as other conditions can lead to inappropriate treatment, as stated in the British Journal of Dermatology 1, 4
Underestimating the extent of epidermal detachment can lead to inadequate treatment, as suggested by the British Journal of Dermatology 1
Neglecting mucosal involvement can lead to significant morbidity, according to the British Journal of Dermatology 1, 4
Failing to consider protein C deficiency in cases of warfarin-induced skin necrosis can lead to inadequate treatment, as stated in Chest 7, 8