Golfer’s vasculitis

Abstract

A 61-year-old female with pernicious anemia presented with a 20-year history of walking-induced, erythematous, macular rash on her lower extremities. The rash was usually provoked by prolonged walking, especially in hot weather, although walking for as little as 30 minutes could trigger it as well. The eruption usually started at her shin (Panel A) and could extend all the way to her lower abdomen. She was treated with cortisone cream, vitamin E, and holistic approaches without significant improvement. Previous extensive workup for autoimmune diseases was non-revealing.Golfer's vasculitis, also known as exercise-induced vasculitis (EIV), is a specific form of benign cutaneous vasculitis affecting healthy individuals. 1,2 It is underappreciated, and mostly misdiagnosed as erythematous rash, or a purpuric itchy eruption. Unlike other idiopathic cutaneous vasculitides, golfer's vasculitis constitutes a stereotyped clinical entity, occurring after prolonged exercise such as a long walk or golf session. Other activities, such as dancing, cycling, or intensive cleaning are also reported as rare triggers. 1 A hot climate is considered a prerequisite; however, milder eruptions may occur in some patients in cooler seasons. Sun exposure does not appear as a contributory factor. Skin manifestations of golfer's vasculitis can vary among patients, including isolated erythematous rash, isolated purpura, erythematous rash and purpura, pseudo-urticaria, and/or lower extremity edema.The etiology of golfer's vasculitis is unknown. It is likely multifactorial and related to excessive heat production during prolonged exercise, leading to muscular hyperthermia and tissue damage, exercise-related immune system alteration, venous stasis, and alterations in skin blood flow. [1][2][3] Histological features on skin biopsy range from urticarial vasculitis with eosinophils to typical leukocytoclastic vasculitis. 1,2 Complement components C3 and C1q, immunoglobulin IgM, fibrinoid necrosis deposition, and erythrocyte extravasation can be present as well. 1,3 In most cases, cutaneous lesions resolve within a few days, but relapses are very frequent.Treatment of golfer's vasculitis is not standardized or mandatory given its self-resolving nature. Topical corticosteroids are reported to be beneficial at the acute phase, although no clinical trials have evaluated their efficacy. Properly fitting compression stockings decrease recurrence in about one-half of cases but can sometimes increase the symptoms. 1 Antihistamines have been used in some cases but have not been shown to be effective. 1

Saturday night purpura: An uncommon presentation of exercise‐induced vasculitis

“…The pathogenesis of EIV remains uncertain and is likely multifactorial. 3 Possible contributory factors include excessive heat production during vigorous exercise leading to muscle hyperthermia and tissue damage. In addition, alterations of the immune system (with an increase in circulating immune complexes and complement activation) increase muscular arterial flow, and greater capillary permeability, causing petechiae and vasculitis.…”

“…The pathogenesis of EIV remains uncertain and is likely multifactorial 3 . Possible contributory factors include excessive heat production during vigorous exercise leading to muscle hyperthermia and tissue damage.…”

“…7,8 Although some authors have suggested that EIV is a form of exercise-induced capillaritis exacerbated by underlying subclinical venous hypertension, 9 most authors classify it as a benign cutaneous variant of leukocytoclastic vasculitis. [2][3][4][5] In fact, leukocytoclastic vasculitis is the main histopathological finding and neutrophils, with associated karyorrhexis, predominate in the perivascular infiltrate. 2,5 Since EIV is considered a benign vasculopathy, in the absence of a primary inflammatory vasculitis, some authors prefer the term exercise-induced purpura.…”

“…The disorder is typically triggered by prolonged or excessive exercise in warm weather. Lesions appear as erythematous, urticarial, or purpuric plaques symmetrically distributed on the lower extremities, sparing areas of compression (eg, by socks), and it is not associated with any systemic symptoms 2‐5 . EIV appears most commonly in women over the age of 50 years and has it rarely been reported in children; only six cases have been published 2,5,6 .…”

“…Lesions appear as erythematous, urticarial, or purpuric plaques symmetrically distributed on the lower extremities, sparing areas of compression (eg, by socks), and it is not associated with any systemic symptoms. [2][3][4][5] EIV appears most commonly in women over the age of 50 years and it has rarely been reported in children; only six cases have been published. 2,5,6 We present a case of EIV in an adolescent male that appeared after a night of dancing.…”