Actinic Purpura: the unsightly botches that Donald Trump often displays on the back of his hands

Many commentators have wondered what the bothches on Trump’s hands might be and whether they signify some sinister cause. The White House medical updates and Trump himself have attributed the bruising to a combination of factors:

• Frequent Handshaking: Both Trump and his physician have claimed that shaking hands with thousands of people causes minor soft-tissue trauma.
• Aspirin Use: His medical team disclosed that he takes daily low-dose aspirin as part of a routine cardiovascular prevention regimen, which thins the blood and allegedly increases the likelihood of noticeable bruising from minor bumps.
• Venous Insufficiency: Medical disclosures have also noted a diagnosis of chronic venous insufficiency which allegedly can contribute to bruising.

In my view, these official explanations are a good example of the BS that comes out of the White House these days. The marks Trump regularly displays on his hands are most likely actinic purpura, also known as senile purpura, or solar purpura, or Bateman’s purpura. This is a common and completely benign condition that causes easy bruising on the hands and forearms of older adults. First described by Bateman in 1818, this dermatosis presents as dark purple, irregularly shaped blotches on photo-exposed areas, particularly the dorsal surfaces of the hands and extensor aspects of the forearms. Despite its somewhat alarming appearance, actinic purpura has no health consequences and does not indicate systemic disease.

The condition affects approximately 10 per cent of people over age 50, with prevalence rising to around 30 per cent after age 75. It is painless and occurs more frequently in men than women and is strongly associated with fair skin tones and cumulative lifetime ultraviolet exposure. The prevalence increases exponentially with advancing age, reflecting the progressive nature of the underlying pathophysiological changes.

Actinic purpura results from increased fragility of superficial capillaries due to atrophy or damage of dermal connective tissue. Chronic ultraviolet radiation degrades collagen and elastin fibres, weakening the structural support for blood vessels. Ageing contributes through skin thinning and changes in fat distribution that bring vessels closer to the surface. Various medications exacerbate the condition, including corticosteroids, aspirin, warfarin, clopidogrel, and non-steroidal anti-inflammatory drugs. Minor trauma, such as negligible bumps, scratching, or poking, readily ruptures these fragile vessels. The brown pigmentation that occasionally persists after resolution results from haemosiderin deposition from lysed red blood cells.

Patients present with flat red lesions that progress to purple and then darken over time. The lesions are typically painless and non-tender, persisting for one to three weeks before resolution. They may leave permanent brown pigmentation and recur chronically with lifelong reappearance of new lesions. The differential diagnosis includes bleeding disorders, vasculitis, vitamin C deficiency, and drug-induced purpura. Actinic purpura is associated with by normal coagulation and platelet function, absence of inflammation, and confinement to photo-exposed skin areas.

The condition has no health consequences and is not associated with systemic disease or blood dyscrasias. It does not herald severe bleeding elsewhere and has no systemic implications. Crucially, actinic purpura is not associated with coronary or cerebral artery fragility, bleeding disorders, or internal vascular disease.

No specific treatment is required because the condition is self-resolving. Preventive measures include daily sunscreen application, protective clothing to prevent further photodamage, moisturisers to maintain skin suppleness, protective arm clothing to minimise trauma, and reducing topical steroid use on thin skin areas. Citrus bioflavonoids taken twice daily reduced lesions by 50 per cent in 70 seniors in a 2011 study that has not been independently confirmed. Vitamin C supplementation is only helpful if deficiency exists, with no benefit in non-deficient individuals.