What is exercise-induced vasculitis?
Exercise-induced vasculitis is a harmless form of cutaneous small vessel vasculitis. It is also called golfer's vasculitis.
It is a neutrophilic inflammatory disorder involving the small or medium-sized blood vessels of the skin and subcutaneous tissue.
When only the small capillary vessels are involved, it is also called exercise-induced capillaritis.
What are the clinical features of exercise-induced vasculitis?
Exercise-induced vasculitis mainly affects one or both lower legs and thighs, with single or multiple episodes of a rash with the following characteristics:
- Involvement of exposed skin and sparing of skin protected by socks or stockings
- Red patches, urticarial lesions (weals) and purpura (purple spots)
- Oedema (swelling) of the affected leg(s)
- Intense itching, stinging, pain or burning
The patient is otherwise well, without fever, malaise or other symptoms.
Lesions resolve over 3 to 4 weeks. A purplish-brown mark may persist for longer.
Who gets exercise-induced vasculitis?
Patients that present with exercise-induced vasculitis are often female and over 50 years of age. They are most often otherwise healthy and active.
Common activities which can trigger exercise-induced vasculitis include:
- Jogging and running, especially long-distance running
- Hiking and climbing
- Step aerobics
- Body building
It is also suspected that there might be a genetic or familial factor causing susceptibility to exercise-induced vasculitis.
Differential diagnosis of exercise-induced vasculitis
Other forms of cutaneous or systemic vasculitis may be aggravated by exercise but are not primarily due to exercise. In these cases, the vasculitis may be due to an underlying disease or condition. Exercise-induced capillaritis generally presents with milder clinical features.
What causes exercise-induced vasculitis?
As the name implies, exercise-induced vasculitis is typically induced by strenuous muscle activity, particularly during warm and humid weather. It is thought that the temperature regulation mechanisms within the calf muscles break down, leading to reduced venous return and blood stasis. The end result is inflammation and vascular injury.
How is exercise-induced vasculitis diagnosed?
Diagnosis of exercise-induced vasculitis can be difficult. It is based on history and physical examination. Some people may undergo investigations, such as:
- Laboratory tests
- Imaging, eg X-rays and ultrasound scans
- Skin biopsy
Laboratory tests and imaging are undertaken for 2 main reasons.
- To exclude another cause of cutaneous vasculitis
- To determine if other organs are affected, thus diagnosing systemic vasculitis.
Skin biopsy shows leukocytoclastic vasculitis in exercise-induced vasculitis. Direct immunofluorescence examination of new lesions shows complement and immunoglobulins in walls of the blood vessels.
What is the treatment for exercise-induced vasculitis?
Management of exercise-induced vasculitis involves:
- Temporary cessation of vigorous exercise.
- Elevation of affected limb(s)
- Compression stockings to relieve discomfort and speed up healing. They may possibly help prevent exercise-induced vasculitis.
- Nonsteroidal antiiflammatory drugs and antihistamines to reduce symptoms of burning and itch.
Patients with recurrent episodes of exercise-induced vasculitis should avoid vigorous exercise in warm weather. Although there are no reports of their use in exercise-induced vasculitis, active treatments that can control small vessel vasculitis include:
Systemic steroids, eg prednisone, are reserved for severe cutaneous vasculitis eg with blistering or ulceration, and are not necessary for exercise-induced vasculitis.