Widespread Purpura on the Neck and Back

Dear Editor, Purpuric rash on non-dependent body sites may be due to various causes including senile purpura, suction purpura, systemic amyloidosis, and connective tissue diseases. Here, we describe an unusual purpura on non-dependent sites in a middle-aged female resulting from traditional cultural practices. A 53-year-old Caucasian woman, settled in an international social community in Southern India for the past five years, presented to our dermatology outpatient department for her periodic skin examination. While she was being examined for possible actinic keratosis, we noticed a striking finding on her back and neck, in the form of an erythematous-to-violaceous nonpalpable, nonblanchable purpuric rash [Figure 1]. Faced with such a sinister finding, a myriad of differentials were considered including platelet disorders, confluent macular violaceous erythema due to dermatomyositis, systemic amyloidosis, coagulopathies, sunburns, textile dermatitis and traumatic injury. The patient was cautiously interviewed to find a possible history of trauma or abuse. Her complete hemogram and muscle enzyme levels were within normal limits. Much to our surprise, she showed no signs of worry about her examination findings and reassured us that they were merely bruises from Gua Sha therapy, which she had undergone one day ago for chronic back pain and muscle tension.Figure 1: Erythematous-to-violaceous purpuric rash on the back following Gua Sha therapyNon-dependent distribution of a purpuric rash can be associated with numerous potential causes. Senile purpura is characterized by reddish-purple bruises on the skin following minor trauma, usually on the hand and forearm. Suction purpura is a type of mechanical purpura due to the exertion of a negative pressure force on the skin, presenting as small, grouped petechiae. Purpura following traumatic asphyxia may be seen following severe compression of the chest or abdomen, leading to a sudden increase in pressure within the chest cavity, causing blood to be forced backwards into the head and neck. Connective tissue diseases such as dermatomyositis may present with a confluent violaceous-to-erythematous rash on the neck, trunk and back which is usually accompanied by proximal muscle weakness. Systemic amyloidosis may present as “pinch purpura” following minor trauma, as a result of weakening of vessel walls due to deposition of amyloid.[1] Gua Sha is a traditional East-Asian medical practice that involves using smooth tools to scrape the skin [Figure 2], intentionally creating petechiae and ecchymosis. The extravasation of blood in the skin and subcutis is supposed to help counter “blood stasis,” also known as “Sha.” The technique consists of closely timed, repeated, unidirectional press-stroking with a smooth-edged instrument over a lubricated skin area until petechiae appear. The petechiae formed following Gua Sha treatment resolves within two to five days. The lesions may have a pattern determined by the edge of the scraping tool. Following blood extravasation, cell debris is cleared by macrophages. Subsequently, the heme oxygenase enzyme is induced to degrade hemoglobin. Western medical terms for this practice include “coining,” “scraping,” and “spooning.”[2]Figure 2: Wooden Gua Sha toolGua Sha has been advocated for various purposes including relief of muscle pain, breakdown of scar tissue and relief of perimenopausal symptoms. Smaller, smooth-edged tools made of wood or jade are used on the face to relieve puffiness and contour.[3] Gua Sha therapy has been shown to be effective in reducing chronic pain. The proposed mechanisms include a nociceptive effect, counter-irritant mechanism and a powerful placebo effect.[4] In a study conducted in mice, Gua Sha therapy was found to upregulate heme oxygenase-1, as detected by bioluminescence imaging. The exact significance of these findings in health and disease is not well understood, and their relevance in human populations remains to be established.[5] While Gua Sha has been regarded as a generally safe practice, it is contraindicated on areas with a breach in the skin’s integrity or in presence of pre-existing abrasions and sunburns. Although there are no reports of transmission of blood-borne pathogens, it is recommended to use disposable single-use tools to prevent the remote possibility of infection transmission. Gua Sha is not contraindicated in patients with a stable international normalized ratio who are on anticoagulant therapy. However, prolonged and vigorous treatment is best avoided in these patients.[2] The cutaneous effects of Gua Sha treatment must be recognized to prevent inadvertent misdiagnosis of patients. History taking must include a detailed treatment history, including traditional practices like Gua Sha. Purpuric lesions along the lines of stroking, with a pattern sometimes matching the instrument’s edges may aid in arriving at the diagnosis. Although uncommon, a differential diagnosis of scraping-induced purpura must be considered when encountering confluent purpuric lesions in an otherwise healthy patient. Authors’ contributions The manuscript has been read and approved by all authors. All authors meet authorship criteria and that the manuscript represents honest work. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence (AI) The preparation of this manuscript was carried out entirely by the authors without the use of artificial intelligence technologies.