Golfer’s vasculitis

A 61-year-old female with pernicious anemia presented with a 20-year history of walking-induced, erythematous, macular rash on her lower extremities. The rash was usually provoked by prolonged walking, especially in hot weather, although walking for as little as 30 minutes could trigger it as well. The eruption usually started at her shin (Panel A) and could extend all the way to her lower abdomen. She was treated with cortisone cream, vitamin E, and holistic approaches without significant improvement. Previous extensive workup for autoimmune diseases was non-revealing.

Golfer’s vasculitis, also known as exercise-induced vasculitis (EIV), is a specific form of benign cutaneous vasculitis affecting healthy individuals.^1,2 It is underappreciated, and mostly misdiagnosed as erythematous rash, or a purpuric itchy eruption. Unlike other idiopathic cutaneous vasculitides, golfer’s vasculitis constitutes a stereotyped clinical entity, occurring after prolonged exercise such as a long walk or golf session. Other activities, such as dancing, cycling, or intensive cleaning are also reported as rare triggers. ¹ A hot climate is considered a prerequisite; however, milder eruptions may occur in some patients in cooler seasons. Sun exposure does not appear as a contributory factor. Skin manifestations of golfer’s vasculitis can vary among patients, including isolated erythematous rash, isolated purpura, erythematous rash and purpura, pseudo-urticaria, and/or lower extremity edema.

The etiology of golfer’s vasculitis is unknown. It is likely multifactorial and related to excessive heat production during prolonged exercise, leading to muscular hyperthermia and tissue damage, exercise-related immune system alteration, venous stasis, and alterations in skin blood flow.^1–3 Histological features on skin biopsy range from urticarial vasculitis with eosinophils to typical leukocytoclastic vasculitis.^1,2 Complement components C3 and C1q, immunoglobulin IgM, fibrinoid necrosis deposition, and erythrocyte extravasation can be present as well.^1,3 In most cases, cutaneous lesions resolve within a few days, but relapses are very frequent.

Treatment of golfer’s vasculitis is not standardized or mandatory given its self-resolving nature. Topical corticosteroids are reported to be beneficial at the acute phase, although no clinical trials have evaluated their efficacy. Properly fitting compression stockings decrease recurrence in about one-half of cases but can sometimes increase the symptoms. ¹ Antihistamines have been used in some cases but have not been shown to be effective. ¹ Prevention requires wearing lighter clothing and walking shoes, as well as avoiding prolonged exercise during hot weather.^1,2

Panel A.