Perifollicular and Subperiosteal Hemorrhages — Follicular Hyperkeratosis, Perifollicular Petechiae, Purpura & Scurvy Bleeding Signs

Perifollicular and Subperiosteal Hemorrhages:

• What are Perifollicular and Subperiosteal Hemorrhages?
• Follicular Hyperkeratosis
• Perifollicular Petechiae
• Purpura
• Scurvy Bleeding Signs

What are Perifollicular and Subperiosteal Hemorrhages?

Perifollicular and subperiosteal hemorrhages are classic clinical signs associated with vitamin C deficiency (scurvy) and various bleeding disorders. Perifollicular hemorrhage refers to small pinpoint or petechial bleeding that occurs around hair follicles, commonly seen on the lower legs and buttocks. Subperiosteal hemorrhage involves bleeding beneath the periosteum (the membrane surrounding bones), leading to painful swellings and sometimes visible bruising. These signs occur because of fragile capillaries and impaired collagen synthesis, both of which are hallmarks of scurvy.

Perifollicular hemorrhages often present early, while subperiosteal bleeding may indicate more advanced disease. These hemorrhages are not caused by trauma but by weakened blood vessel walls due to defective collagen. Recognizing these findings is important, as they provide key diagnostic clues, especially in populations at risk of vitamin C deficiency such as elderly individuals, patients with malnutrition, or children with restrictive diets. Early identification and vitamin C supplementation usually result in rapid improvement of these bleeding signs.

Follicular Hyperkeratosis

Follicular hyperkeratosis is a skin manifestation often associated with scurvy and perifollicular hemorrhage. It refers to abnormal thickening and plugging of hair follicles by keratin, giving the skin a rough, “gooseflesh” appearance. This hyperkeratosis typically affects the extensor surfaces of the limbs, such as the thighs and upper arms, and is frequently seen in combination with perifollicular petechiae. The abnormal keratinization occurs because vitamin C plays a crucial role in normal keratin metabolism and skin health.

Over time, hyperkeratotic plugs may trap hair shafts, causing them to coil or become corkscrew-shaped, another hallmark sign of scurvy. These dermatological changes are usually painless but serve as visible indicators of underlying nutritional deficiency. Proper dietary intake of vitamin C or supplementation typically reverses follicular hyperkeratosis within weeks, making it a useful clinical sign for both diagnosis and monitoring treatment response.

Perifollicular Petechiae

Perifollicular petechiae are pinpoint red or purple spots that form around hair follicles, particularly in areas such as the lower legs. These occur due to capillary fragility and impaired connective tissue support around the follicles. In scurvy, defective collagen synthesis leads to weakened vascular walls, making them prone to rupture even with minimal pressure. Perifollicular petechiae often precede more extensive bleeding manifestations and are among the earliest cutaneous signs of vitamin C deficiency.

Clinically, these petechiae may be accompanied by perifollicular hyperkeratosis, giving the skin a characteristic pattern that can be recognized on inspection. The petechiae do not blanch under pressure, which helps differentiate them from other vascular skin changes like erythema. Laboratory tests may reveal normal platelet counts, distinguishing scurvy-related petechiae from thrombocytopenic purpura. Supplementation with vitamin C typically results in the resolution of perifollicular petechiae within days to weeks.

Purpura

Purpura refers to larger areas of bleeding under the skin, typically measuring between 4 mm and 1 cm, that result from blood extravasation due to fragile capillaries or coagulation defects. In the context of scurvy, purpura occurs when perifollicular petechiae coalesce or when subcutaneous vessels rupture due to collagen weakness. These lesions often appear on the lower limbs where hydrostatic pressure is highest, and they may be mistaken for vasculitis or platelet disorders.

The distribution of purpura in scurvy is often symmetrical and located around hair follicles. Unlike inflammatory causes, scurvy-related purpura typically lacks systemic inflammatory signs. Patients may complain of tenderness or mild discomfort in affected areas, but systemic symptoms are usually related to anemia or generalized weakness rather than infection. Recognizing purpura in combination with perifollicular changes is crucial for timely diagnosis and treatment of scurvy, especially in children or malnourished adults.

Scurvy Bleeding Signs

Scurvy bleeding signs include perifollicular petechiae, purpura, gingival bleeding, ecchymoses, and subperiosteal hemorrhages. These manifestations occur because vitamin C is essential for hydroxylation of proline and lysine residues during collagen synthesis. Without adequate collagen, blood vessel walls lose integrity and become prone to rupture. Bleeding often starts around hair follicles and gums but can progress to larger areas, including muscles and bones, as the deficiency worsens.

Subperiosteal hemorrhage is particularly characteristic in children with scurvy and can cause severe pain, swelling, and pseudoparalysis of the affected limb. Gingival bleeding with swollen, spongy gums is another hallmark sign, especially in individuals with teeth. These bleeding signs respond dramatically to vitamin C supplementation, often improving within days. Recognizing perifollicular and subperiosteal hemorrhages, along with other scurvy manifestations, remains clinically important even today, as cases continue to be reported worldwide, especially in individuals with poor nutrition or restrictive diets.