Golfer's purpura

The photograph shows a rash consisting of confluent purpuric macules and papules over the distal part of the left leg.

The patient, a healthy man in his fifties, presented to his general practitioner with sudden onset of an asymptomatic rash on both lower extremities. When reviewing the patient's medical history, it emerged that the patient had played several rounds of golf earlier on the day that the rash appeared. It had been a hot summer day, and he had been wearing shorts and long socks. The patient was not taking any medications and had not recently had a fever, infectious disease, muscle/joint pain or weight loss.

Clinical examination revealed a relatively symmetric rash on both lower extremities, consisting of non-blanching confluent macules and papules, with recession of the skin further down the legs in the region covered by the socks. Blood pressure was normal, urine strip testing yielded no results and preliminary blood tests were all within the normal range. No skin biopsy was performed. The rash was consistent with exercise-induced purpura. No specific treatment was prescribed, and at the two-week follow-up, the rash had resolved.

The condition – also known as golfer's purpura or golfer's vasculitis – typically occurs in middle-aged patients after prolonged walking in hot weather (1, 2). Although the term 'vasculitis' is used, there has been debate on whether the condition actually represents a capillaritis – a harmless skin condition caused by inflammation and leakage from the smallest blood vessels due to capillary fragility and venous stasis (2). The rash can affect both lower extremities and cause symptoms such as itching, a burning sensation and stabbing pains, in addition to oedema and urticarial lesions (1).

Golfer's purpura differs from more severe types of vasculitis in that patients are afebrile and experience no general symptoms. The diagnosis of exclusion is primarily based on anamnestic information. In cases of doubt or when the patient appears generally ill, there should be a low threshold for further investigation with skin biopsy, blood tests and urine strip testing. The prognosis is good as the rash typically resolves within one to four weeks, but in some cases, pigment changes may last longer (1).