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Case Report

Oral Ecchymosis in elderly: Senile purpura

Srikanth H Srivathsa
Department of Oral Medicine and Radiology, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India

ABSTRACT
Senile purpura is the clinical condition where purpuric spots and ecchymosis develop at the site of minimal injury. It occurs
due to laxity of the connective tissue. Oral manifestation of this disease is rare and when one encounters such a case,
proper examination with extensive differential diagnosis should be considered along with appropriate investigations. A case
of senile purpura in an elderly patient who had developed oral ecchymosis secondary to denture injury is being reported.

Key words: Ecchymosis, elderly, purpura, senile purpura

Introduction

Case Report

enile purpura (SP) is the term used to describe

ecchymosis/purpuric lesions that occur in the
elderly individuals who are otherwise healthy.
It generally occurs on the exposed surfaces of the
extremities such as arms and legs or on the face
following minor trauma.[1] SP is a benign condition,
occurring primarily as a manifestation of aging,
wherein the blood vessels lack adequate support
from the underlying connective tissue and exhibit
increased capillary fragility.[2] Bateman is believed to
have identified and described this condition in 1836,
for the first time.[3] Although the etiopathogenesis
is incompletely understood, it is considered as a
physiologic condition occurring due to aging.[4] It is
unlikely that palatal ecchymosis is encountered on
a day-to-day basis, especially in the elderly. When
encountering such a case, it is imperative for all oral
diagnosticians to consider the possibility of SP, which
is a benign condition.

A 72-year-old female patient visited the outpatient

department with the complaint of broken maxillary
complete denture of 4 days duration. Her medical and
surgical histories were not significant. Patient was
apparently healthy and was not under any medications
for any systemic illness. History revealed that the
dentures had been fabricated 8 years back and that
the maxillary denture accidently fell and broke. Citing
aesthetic reasons, she continued to wear the unrepaired
denture for the past 4 days. On examination of the
oral cavity, the maxillary and mandibular completely
edentulous arches were evident. The hard palatal
mucosa showed bilaterally diffuse linear ecchymosis
and purpuric spots, each measuring approximately
2 cm 0.5 cm in size, more pronounced on the lateral
aspects of the palate, corresponding to pressure areas
from the denture. Rest of the mucosa was normal. Upon

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How to cite this article: Srivathsa SH. Oral Ecchymosis in elderly:

Senile purpura. J Indian Acad Oral Med Radiol 2015;27:331-3.

Address for correspondence: Dr. Srikanth H Srivathsa, Department of Oral Medicine and Radiology, Sri Hasanamba Dental
College and Hospital, Vidyanagar, Hassan - 573 202, Karnataka, India. E-mail: srikanth_vathsa2000@yahoo.com
Received: 22-01-2015 Accepted: 18-10-2015 Published: 21-11-2015

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Srivathsa SH: Oral ecchymosis in elderly

palpation, the area was non-tender and non-blanching

[Figure 1]. On questioning the patient about the palatal
lesions, she replied that she had neither noticed it nor
had any symptoms. A detailed history of bleeding or
clotting disorders including family history was elicited,
which was found to be negative. There was no history
of similar purpuric areas elsewhere on the body nor
any history of easy bleeding tendencies of recent onset.
There was no history of spontaneous bleeding, easy
fatigability, loss of weight or appetite, fever, or recent
viral infections. Examination of the extremities showed
no evidence of purpura or ecchymosis on the exposed
parts. A complete hemogram with peripheral smear
showed parameters within normal limits. Patient was
mildly anemic with the hemoglobin being 12.6 g%. There
was no thrombocytopenia and the clotting factors were
within limits. International Normalized Ratio (INR)
was 0.9, which was within limits. Liver function tests
showed normal values of serum glutamic oxaloacetic
transaminase (SGOT) and serum glutamic pyruvic
transaminase (SGPT). Also, a smear examination
fromthe palate for Candida was negative, which ruled
out superficial fungal infection.

of physiologic aging due to laxity of the connective

tissue. Any minor trauma to the blood vessels results
in ecchymosis or purpura. Furthermore, it is believed
that there is delayed resolution of the ecchymosis
due to abnormal macrophage function.[4] Also, with
aging, there is reduction in elastic and collagen fibers
with increased susceptibility to external trauma. [5]
Chronic usage of certain drugs like the nonsteroidal
anti-inflammatory drugs (NSAIDs), corticosteroids,
or anticoagulants may predispose to the development
of SP in some elderly patients. [2] Deficiency of zinc [4]
and underlying liver disorders are also postulated in
the development of SP.[6] The case presented here had
nomal liver function, was not under medications, and
was otherwise healthy.

Based on the above features, the case was diagnosed as

SP. The patient was advised to discontinue the use of
the fractured denture and was recalled for review after
1 week. The following week, ecchymosis had completely
resolved [Figure 2]. Fabrication of new dentures was
done, with the operator being cautious and gentle
to prevent development of new lesions. Patient was
counseled and educated about the condition and the
possibility of development of such lesions elsewhere
in the body or in the oral cavity. A 1-month follow-up
failed to reveal any new lesions.

Clinical features
SP presents as non-palpable purpuric or ecchymotic
spots on the extensor surfaces of the arms and feet and
are non-tender.[3] Intraorally, SP presents as ecchymosis
commonly occurring on the palate, tongue, and on the
lips.[1] Ecchymosis was noted on the denture-bearing
surfaces on the palate and the rest of the oral mucosa was
spared in the case described here, who was otherwise
healthy. In contrast, the subjects in the previously
reported cases had ecchymosis on the palate secondary
to prolonged usage of medications along with the use
of dentures.[1] Hence, minor trauma from the ill-fitting
dentures resulted in palatal ecchymosis in the present
case. Histopathologically, SP shows vascular ectasia with

Discussion
Etiopathogenesis
SP is a benign condition whose pathogenesis is not
very well understood. It is considered as a consequence

Figure 1: Intraoral photograph showing ecchymosis on the palate

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Epidemiology
SP of the skin is rather an uncommon condition.
The prevalence is in the range of 1-14% in different
populations.[3,5,7,8] Prevalence of oral manifestations of
SP has not been studied so far. No gender difference can
be found,[3,5] but it exclusively occurs in the elderly and,
hence, the name senile purpura.

Figure 2: One-week follow-up photograph showing clearing of the

ecchymosis

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Srivathsa SH: Oral ecchymosis in elderly

extravasated erythrocytes, with degenerated collagen

fibers and no vasculitis.[3,9]
Differential diagnosis
Differential diagnosis includes ecchymosis and purpura
due to other causes such as myleodysplastic syndrome,
leukemia, qualitative and quantitative platelet disorders,
and coagulative disorders.[2] It is mandatory to perform
investigations to rule out any underlying serious medical
conditions. Hematologic investigations such as complete
hemogram with peripheral smear examination, liver
function tests, prothrombin time (PT), activated partial
thromboplastin time (aPTT), and INR are performed.
In addition, serum zinc estimation can also be done.[2-4]
Essentially, all the parameters will be under limits in SP,
just as in the present case.
Management
SP, a common dermatologic condition with no clinical
outcome, requires no special management protocol. The
patient needs to be reassured about the benign nature
of the disease and cautioned about minor trauma as an
etiologic factor. Furthermore, careful handling of oral
mucosal tissues is of greatest importance in avoiding oral
ecchymosis.[1,3] In a clinical trial, oral citrus bioflavonoid
has been successfully utilized to demonstrate reduced
episodes of development of purpura/ecchymosis.[10]
Precautions for the dental caregiver
Utmost care is to be taken while treating patients
with a history of SP, as there is easy bleeding due
to minor trauma. The oral tissues are to be handled
gently, particularly during fabrication of dentures and
adjustment of pressure points, and usage of saliva
ejectors or suction tips should be avoided.[1]

Conclusion
This case has been successful in depicting the oral
manifestations of SP in an elderly subject with no

previous history of SP. Hematologic investigations

proved to be beneficial in diagnosing this rare
condition of oral ecchymosis. Oral manifestations of
SP, although rare, should be included in the differential
diagnosis along with other serious medical conditions.
Furthermore, the importance of gently handling our
elderly population, both physically and emotionally,
need not be overemphasized.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.

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