Purpura refers to the appearance of purple spots or patches of varying sizes on the skin, characterized by being non-raised upon touch and non-fading upon pressure. In ancient medical texts, this condition falls under the categories of "purpura" and "purplish macula." The initial stage is associated with a blood heat excess pattern, similar to yang macula; if it persists and recurs over a long period, leading to the loss of vascular containment, it manifests as a deficiency pattern, akin to yin macula. In severe cases, symptoms such as epistaxis, gingival hemorrhage, and bleeding from the ears, eyes, and internal organs may occur. Since purpura is a hemorrhagic disorder, it should be clinically differentiated from febrile maculae and pediatric scarlatina.

bubble_chart Pattern Analysis

1. Yin Deficiency with Blood Heat︰The rash appears purplish-red or bright red, mostly seen on the lower legs, or accompanied by epistaxis, gingival hemorrhage, along with low-grade or high fever, night sweats, flushed cheeks and red lips, a red tongue with scant coating, and a wiry, thin, rapid pulse. This is due to yin deficiency with internal heat, where heat forces blood out of the vessels, causing it to overflow into the skin. Hence, the rash is purplish-red and bright, and the bleeding is often bright red. As heat scorches and damages yin, symptoms such as flushed cheeks, red lips, night sweats, a red tongue with scant coating, and a wiry, thin, rapid pulse occur. Treatment involves cooling blood and clearing the nutrient aspect, nourishing yin, and reducing fire. The recommended formulas are Rhinoceros Horn and Rehmannia Decoction or Yuxue No. 1.
2. Spleen Deficiency with Blood Weakness︰Purpura is more common on the legs, appearing as pale purple or bluish-dark patches, accompanied by shortness of breath, spontaneous sweating, mental fatigue, reduced appetite, shallow yellow complexion, a pale and tender tongue with scant coating, and deep, thin, weak pulses. This is due to qi deficiency and blood weakness, the spleen failing to control and contain, and blood not following meridian tropism, instead leaking outward to the skin. Hence, the purpura appears light in color or forms dark patches, or there may be nosebleeds and yellow-tinged blood seeping from the gums. Qi deficiency leads to weakened defensive qi, resulting in sweating upon exertion, bodily fatigue, and lack of strength. Spleen deficiency impairs transportation, leading to a dull yellow complexion, reduced appetite, a pale and tender tongue, and thin, weak pulses. Treatment focuses on tonifying qi to control blood, using Returning to Spleen Decoction or Nourishing Blood Formula No. 2. If the condition persists unhealed, tonifying and replenishing blood and essence is necessary, adding blood-nourishing and essence-tonifying substances such as Tortoise Carapace, Donkey-hide Gelatin, and degelatined deer-horn.
3. Dampness-heat Wind Toxin︰Purple-red or dark purple ecchymoses appear on the lower limbs or buttocks, varying in size, appearing and disappearing intermittently, or with slightly swollen eyelids, fever, and swollen, painful joints. If accompanied by papules or cloud-like patches, the skin may itch, or there may be abdominal pain, bloody stool, hematuria, a red tongue with a yellow, thick, greasy coating, and a floating, slippery, rapid pulse. Treatment involves {|###|}dispelling wind and drying dampness{|###|}, harmonizing blood, and resolving stasis. The formula used is Forsythia Toxin-Vanquishing Powder with modifications, or dispelling wind and drying dampness and blood-harmonizing decoction. This condition often arises from internal dampness-heat clashing with external wind-toxins, leading to disharmony of nutrient-defense, disruption of the collaterals, and blood extravasation. Manifestations include dark purple or bluish-purple ecchymoses resembling grapes, varying in size and shape, sometimes merging into patches, appearing and disappearing intermittently, or persisting without fading. Due to the combined pathogens of wind-dampness affecting the muscles, skin, and joints, symptoms may also include fever, slightly swollen eyelids, itchy papules, swollen and painful joints, and abdominal pain due to qi and blood stasis. If the yin collaterals are injured, bloody stool and hematuria may occur.

bubble_chart Documentation

1. Yizong Jinjian Waike Xinfa Essentials. Infant Section Discussion on purpura: "This condition is often caused by infants being affected by pestilent qi, which stagnates in the skin and condenses to form. Large and small purplish macula spots, resembling grapes in color and shape, appear all over the body, especially on the legs and shins; in severe cases, the evil toxin affects the stomach, leading to gum ulceration, foul-smelling bleeding, resembling ulcerative gingivitis, and the purplish macula spots become lighter in color. Over time, it can cause emaciation. At the onset, it is advisable to take Antelope Horn Powder, and for prolonged deficiency, it is advisable to take Stomach and Spleen Decoction, and rinse the mouth with rice bran water."