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  • Presentation

Clinical Approach to Vasculitis: Diagnosis, Workup, and Management of Small and Medium Vessel Disease

Description

The talk explained how to approach vasculitis by linking vessel size, skin findings, and systemic involvement. Small vessel vasculitis typically causes palpable purpura, petechiae, or small ulcers on the lower legs, while medium vessel disease can produce livedo reticularis, retiform purpura, nodules, larger jagged ulcers, neuropathy, and renovascular hypertension. The speaker emphasized that vasculitis is a clinicopathologic diagnosis, so biopsy of a fresh lesion is essential, along with direct immunofluorescence when appropriate. The key initial evaluation is a careful review of systems and exam to determine whether disease is skin-limited or systemic, with the urinalysis highlighted as the single most important first lab to detect occult renal involvement. In straightforward, first-episode skin-limited small vessel vasculitis, basic labs such as CBC, BMP, and UA are usually sufficient, while indiscriminate testing like ESR/CRP, broad serologies, or screening imaging is often low yield. More extensive workup is reserved for recurrent, persistent, or symptomatic cases and may include infectious serologies, ANA, rheumatoid factor, complement levels, ANCA, cryoglobulins, and other targeted tests based on the presentation. The lecture also reviewed key entities: IgA vasculitis, which requires close renal monitoring and can be associated with GI, joint, renal, and sometimes malignancy-related disease in older adults; urticarial vasculitis, especially hypocomplementemic forms, which suggests higher systemic risk; and polyarteritis nodosa, a medium vessel vasculitis requiring deep biopsy and often angiographic evaluation for aneurysms. Management depends on severity: skin-limited disease is often self-limited and treated conservatively or with agents like colchicine, dapsone, or azathioprine if chronic, while systemic disease, lupus, renal involvement, or other organ-threatening features require more aggressive therapy and specialty involvement.

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Conclusions

  • Vasculitis diagnosis is best approached by matching lesion morphology and involved vessel size to likely organ involvement, because skin findings often predict whether disease is small- or medium-vessel in nature.
  • A biopsy with strong clinical-pathologic correlation is essential, since many conditions can mimic vasculitis clinically or even histologically.
  • In straightforward skin-limited small vessel vasculitis, the safest and most useful initial workup is limited, with urinalysis as the single most important screening test for occult renal disease.
  • Review of systems and exam should drive additional testing, because indiscriminate lab panels and imaging are usually low yield and can create more confusion than benefit.
  • Most cases of cutaneous small vessel vasculitis are self-limited and skin-limited, but persistent, recurrent, or symptomatic disease warrants more evaluation and often treatment.
  • Abnormal urinalysis, systemic symptoms, or medium-vessel skin findings should prompt a broader search for systemic disease such as IgA vasculitis, lupus, cryoglobulinemia, ANCA-associated vasculitis, or PAN.
  • IgA vasculitis often looks like ordinary small vessel vasculitis on the skin, but renal involvement is common enough in adults that frequent urinalysis and blood pressure monitoring are necessary.
  • Urticarial vasculitis is uncommon but should be suspected when wheals last more than 24 hours, burn, leave bruising, or occur with systemic symptoms, and complement levels are the key prognostic test.
  • Hypocomplementemic urticarial vasculitis is more likely than normocomplementemic disease to reflect systemic involvement such as lupus, arthritis, pulmonary disease, or glomerulonephritis.
  • Medium-vessel vasculitis, especially polyarteritis nodosa, is suggested by livedo racemosa, nodules, retiform purpura, ulcers, or digital necrosis and may require deep biopsy or vascular imaging.
  • Initial management should be tailored to severity and underlying cause, with aggressive systemic therapy reserved for renal or other organ involvement and conservative measures often sufficient for mild skin-limited disease.
  • There is a major evidence gap in treatment of skin-limited vasculitis, so current practice still relies heavily on expert opinion, case series, and ongoing multicenter trials such as ARAMIS.
  • Overall, the presentation argues that a structured, symptom-guided, biopsy-confirmed approach improves diagnostic accuracy while avoiding both under-testing and over-testing in vasculitis care.
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