Easy bruising

INTRODUCTION — Easy bruising is a common complaint in medical practice for both primary care clinicians and hematologists. Easy bruising can be defined as bruising without a history of trauma or bruising after minor trauma that would not have caused bruising in the past. Differentiating between bruising that might be considered normal versus clinically significant is challenging given that there may not be specific symptoms and signs.

This topic will describe particular aspects of the clinical evaluation that can aid a provider in distinguishing bruising that is due to a pathologic versus a benign process. Specific disorders associated with bruising and the approach to patients with a bleeding diathesis are discussed in detail elsewhere. (See "Inherited platelet function disorders (IPFDs)" and "Approach to the child with unexplained thrombocytopenia" and "Diagnostic approach to thrombocytopenia in adults" and "Approach to the child with bleeding symptoms" and "Approach to the adult with a suspected bleeding disorder".)

EPIDEMIOLOGY — In one United States survey of 500 healthy adults, 18 percent reported easy bruising [1]. This finding is consistent with many other studies in which the frequency of easy bruising in healthy individuals ranged from 12 to 55 percent [2,3]. Women are more likely than men to report easy bruising [1,4].

PATHOPHYSIOLOGY — A bruise (ecchymosis) is a collection of blood beneath the skin resulting from extravasation of blood from surrounding vessels. Easy bruising can result from abnormalities affecting the blood vessels themselves, the surrounding skin and subcutaneous structures, platelet number and function, or coagulation cascade function. (See "Overview of hemostasis" and "Approach to the adult with a suspected bleeding disorder".)

Physical injury to a blood vessel normally triggers a vigorous physiologic response. Damage to endothelial tissue causes activation and adhesion of circulating platelets with the assistance of von Willebrand factor. This in turn results in the rapid formation of a platelet plug at the site of injury. Stabilization of the plug via fibrin deposition subsequently results from activation of the coagulation cascade (figure 1). A problem or defect at any step of this process will increase the risk of abnormal bruising and bleeding, regardless of the degree of trauma.

ETIOLOGY — The etiology of bruising can be broadly classified by the anatomic/physiologic defenses against bleeding (table 1) [5]. The following list includes the main categories with their most commonly associated etiologies:

●Disorders of blood vessels and surrounding tissue (eg, physical abuse, vitamin C deficiency, connective tissue disease)

●Platelet abnormalities (eg, drugs (table 2), systemic illness including infections, von Willebrand disease)

●Coagulation disorders (eg, coagulation factor deficiency, liver disease, vitamin K deficiency)

EVALUATION — As bruising is a common complaint, the clinician should be familiar with important symptoms and signs that require further workup. The history and physical examination are more useful than laboratory testing in this initial assessment. The principal goal of the clinical history and examination is to distinguish easy bruising from normal bruising, from other skin lesions that can be mistaken for bruising, and from physical abuse. Laboratory testing is used in selected cases for further evaluation.

History — A thorough history is integral to a successful evaluation and helps to avoid unnecessary laboratory testing. Questionnaires used in hematology clinics can help identify individuals who need further workup; however, these questionnaires tend to be detailed and their usefulness is still being evaluated [6]. For the primary care clinician, the greatest value comes from their high negative predictive value and the ability to avoid the workup for common disorders such as von Willebrand disease. (See "Clinical presentation and diagnosis of von Willebrand disease".)

It is important to remember that the bleeding history depends on the patient having been exposed to challenges to hemostasis such as surgery, tooth extractions, or menorrhagia. In young children, the bleeding history and the presence of a family history may be negative, and they still require evaluation [7].

Associated trauma — One of the first questions that should be asked is whether there was any trauma associated with the bruises. Normal bruising is to be expected with moderate to severe trauma. Easy bruising is suspected when the patient denies any history of trauma or if there is bruising out of proportion to mild trauma. By definition, easy bruising is not associated with moderate to severe trauma.

A lack of physical trauma related to a bruise raises suspicion of an underlying bleeding diathesis. However, this can sometimes be misleading. Some patients, particularly those who are fair skinned, overweight, and female, can develop bruising with minimal trauma and may not remember being injured.

In the setting of physical abuse, a history of physical trauma may not be volunteered. Young children, women, and older adults are at higher risk for nonaccidental trauma. It may be helpful to interview the patient without the presence of the patient’s caregiver or partner to help determine if the patient has been abused. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Physical examination' and "Intimate partner violence: Diagnosis and screening", section on 'Clinical presentation' and "Elder abuse, self-neglect, and related phenomena", section on 'Warning signs'.)

Location and severity — The location of bruising on the distal extremities suggests normal bruising, likely due to known or unknown trauma with activity (eg, falls, sports, bumping into furniture). By contrast, easy bruising usually occurs on multiple areas of the body.

Severity and frequency are also important; patients with generalized bruising and/or large, frequent bruises may be more likely to have a true bleeding disorder. Easy bruising is considered significant when there are five or more bruises greater than 1 cm in diameter (as defined by the International Society of Thrombosis and Hemostasis) [6]. (See "Approach to the child with bleeding symptoms" and "Approach to the adult with a suspected bleeding disorder".)

Bleeding history — Any history of significant bleeding that accompanies bruising should alert the clinician to an underlying bleeding disorder.

A patient's prior history of invasive procedures or surgery, including dental work and past deliveries, should be obtained. Procedures requiring transfusion raise the index of suspicion regarding an underlying hemorrhagic tendency. Inquiring whether the bleeding was immediate or delayed can also be helpful; disorders associated with platelet dysfunction may demonstrate immediate bleeding, compared with a more delayed onset with coagulation cascade disorders (table 3). (See 'Pathophysiology' above.)

A history of surgical procedures or other major injury without abnormal bleeding is good evidence against the presence of a significant inherited bleeding disorder. (See "Approach to the adult with a suspected bleeding disorder", section on 'Patient history'.)

The age of onset of symptoms may distinguish between a congenital versus an acquired bleeding disorder. Problems with bruising since childhood suggest a possible congenital disorder. By contrast, onset of symptoms in middle age or later suggests an acquired condition or comorbid state that predisposes to bleeding.

The menstrual history may also help identify a bleeding disorder. A female patient may notice that problems with bleeding started during menarche. Menorrhagia (menstrual flow that does not taper after more than three days) and metrorrhagia (bleeding in between periods) are common in women with bleeding disorders.

The patient should also be asked about bleeding with minor injuries (eg, shaving, cuts, falls). Associated bleeding from other sites (eg, recurrent epistaxis, gingival bleeding, hemarthrosis) should prompt further investigation for an underlying bleeding disorder.

Medications — A detailed inventory of medication exposures should include prescriptions drugs, over-the-counter medications, and dietary supplements (eg, vitamin E, ginger, gingko). Several medications are associated with an increased risk of bruising (table 2).

Drug-related bruising is most often related to nonsteroidal antiinflammatory drugs (NSAIDS), anticoagulant medications, antiplatelet agents, and glucocorticoids. Other commonly used agents that can predispose to bleeding include antidepressants (eg, fluoxetine, sertraline, paroxetine) and antibiotics (eg, penicillins, cephalosporins).

Nutrition — Bruising can result from a number of underlying nutritional problems, including deficiencies of dietary protein, vitamin C, and vitamin K. These deficiencies are less common in more developed countries where these nutrients are readily accessible in the average diet. However, certain populations may be prone to these nutritional deficiencies:

●Protein malnutrition is more common in less developed countries, where access to protein-rich foods is limited, and among individuals with specialized diets who avoid protein. (See "Healthy diet in adults" and "Malnutrition in children in resource-limited settings: Clinical assessment".)

●Vitamin C deficiency, or scurvy, occurs mostly in severely malnourished individuals, including institutionalized, chronically ill patients and those with alcohol abuse. (See "Overview of water-soluble vitamins", section on 'Vitamin C (ascorbic acid)'.)

●Vitamin K deficiency is more common among those with bacterial overgrowth, celiac disease, chronic pancreatitis, inflammatory bowel disease, and alcohol abuse. (See "Overview of vitamin K", section on 'Vitamin K deficiency'.)

Family history — The patient should be asked if there is any easy bruising or bleeding among the patient’s family members. A family with only males affected suggests an X-linked disorder such as factor VIII or factor IX deficiency. By contrast, a family with males and females affected equally suggests an autosomal disorder such as von Willebrand disease, which is the most common congenital disorder of hemostasis. The less common disorders, such as inherited factor V and factor XI deficiencies, have a similar autosomal inheritance pattern. It is important to note, however, that a negative family history of easy bruising or bleeding does not exclude the possibility of hemophilia due to de novo mutations, a pedigree that lacks biological males, or inaccurate information. (See "Approach to the child with bleeding symptoms" and "Clinical manifestations and diagnosis of hemophilia" and "Inhibitors in hemophilia: Mechanisms, prevalence, diagnosis, and eradication" and "Factor XI (eleven) deficiency".)

Physical examination — The appearance of bruising may assist with diagnosis of the underlying etiology. Bruises should be distinguished from other forms of subcutaneous bleeding, which may also occur along with bruising. The presence of other examination findings may also help narrow the diagnosis.

Appearance and distribution — The distribution of bruising can be helpful. Bruises related to normal physical activities tend to appear on distal upper and lower extremities. For children one to three years old, bruises are commonly found on the anterior tibia and knee, followed by upper legs and forehead, as a result of falling from learning how to walk or run. Older patients may be at increased risk of bruising from falls and poor tissue turgor, leading to bruises over the upper extremities when being assisted with ambulation.

Bruises appearing on the trunk, back, or face should raise one’s suspicion of an underlying bleeding disorder and/or the possibility of physical abuse in both children and older adults. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Physical examination' and "Intimate partner violence: Diagnosis and screening", section on 'Clinical presentation' and "Elder abuse, self-neglect, and related phenomena", section on 'Warning signs'.)

The color of the bruising may indicate how long ago a traumatic injury occurred [5]. Most bruises are often characterized as “black and blue.” Within a day or two of onset, bruising may be red-brown. Over several days, bruises can turn to green as hemoglobin is converted to biliverdin, and then yellow as biliverdin is catabolized to bilirubin.

Bruises should be distinguished from telangiectasias. Whereas bruises are generally dark and dull in color, telangiectasias are bright and usually red (picture 1). Telangiectasias over the lips, tongue, nasal cavity, and skin are indicative of hereditary hemorrhagic telangiectasia. (See "Clinical manifestations and diagnosis of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)", section on 'Clinical features'.)

Other forms of bleeding — Normal bruising from trauma can be confused with other types of bleeding, including petechiae and purpura. Normal bruises are usually small and superficial in depth. They do not spread into deeper tissues beyond the skin. The presence of petechiae and purpura suggest a bleeding disorder rather than normal bruising.

Petechiae are small capillary hemorrhages that appear smaller than bruises. They characteristically develop in crops in areas of increased venous pressure, such as the dependent parts of the body (picture 2). Petechiae are the smallest bleeding lesions (pinhead in size), and suggest problems with platelet number or function. Petechiae are not normal and always need to be further evaluated. (See "Diagnostic approach to thrombocytopenia in adults", section on 'Skin and other sites of bleeding' and "Approach to the adult with a suspected bleeding disorder".)

Purpura are larger in size than petechiae with variable shape and involve bleeding into subcutaneous tissues. Purpura can be seen in a variety of bleeding disorders, including thrombocytopenia and coagulation cascade disorders. Palpable purpura can be seen in vasculitic processes such as immunoglobulin A (IgA) vasculitis (Henoch-Schönlein purpura) (picture 3). These lesions may also be painful or tender. An underappreciated phenomenon is so-called “senile purpura,” which is seen in patients over age 65 years (picture 4). Senile purpura are non-palpable, purple bruises with small red patches that fade to brown over a span of a few weeks. They are found on the forearms and legs due to loss of subcutaneous tissue with aging [8]. Psychogenic purpura is a rare and poorly understood clinical presentation of unexplained painful lesions, mostly on the extremities and/or the face, and is virtually always associated with psychiatric illness. (See "Purpuric skin lesions (petechiae, purpura, and ecchymoses) in children: Evaluation" and "Immune thrombocytopenia (ITP) in adults: Clinical manifestations and diagnosis" and "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis" and "Diagnosis of immune TTP" and "Photoaging", section on 'Photoaging in individuals with phototypes I to IV' and "Psychogenic purpura (Gardner-Diamond syndrome)" and "Diagnostic approach to thrombocytopenia in adults", section on 'Skin and other sites of bleeding'.)

Spontaneous hemarthrosis, or bleeding into a joint space, is always abnormal and indicative of a bleeding disorder. Hemarthrosis is commonly seen with coagulation disorders (eg, factor VIII and IX deficiencies). (See "Overview of hemarthrosis", section on 'Bleeding disorders'.)

The presence of any of these clinical examination findings, along with pertinent positive findings from the bleeding history, can help differentiate between platelet versus clotting factor disorders (table 4).

Other findings — Specific non-dermatologic findings can also be informative and should be assessed during the physical examination:

●Lymphadenopathy may indicate infection, connective tissue disease, or lymphoid malignancy. (See "Peripheral lymphadenopathy in children: Evaluation and diagnostic approach" and "Evaluation of peripheral lymphadenopathy in adults".)

●Hepatosplenomegaly may indicate systemic disease or chronic liver disease. (See "Hemostatic abnormalities in patients with liver disease".)

●Hypermobile joints or skin hyperelasticity can be seen with Ehlers-Danlos syndrome. Bruising in patients affected with the syndrome appears to be due to decreased connective tissue support surrounding a traumatized vessel. (See "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes".)

●Mitral valve prolapse and joint laxity are commonly seen in patients with Marfan syndrome. (See "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders", section on 'Clinical manifestations of MFS'.)

Other physical signs associated with rare conditions are listed in a table (table 1).

Laboratory testing — Laboratory evaluation for bruising should be considered as an adjunct to performing a good history and physical examination. No laboratory evaluation is generally necessary in patients who meet all of the following criteria:

●Distribution of bruising mainly along distal extremities, especially if associated with trauma

●No other evidence of bleeding (eg, recurrent epistaxis, gingival bleeding, hemarthrosis)

●No personal or family history of significant unexpected bleeding

In all other patients, baseline assays including a complete blood count (CBC) with differential and platelet counts, prothrombin time (PT), and activated partial thromboplastin time (aPTT) should be performed [9]. If these studies are normal, screening for von Willebrand disease is advised. (See 'CBC, PT, and aPTT' below.)

Laboratory evaluation of patients undergoing preoperative testing is discussed elsewhere. (See "Preoperative assessment of bleeding risk", section on 'Laboratory testing'.)

CBC, PT, and aPTT — Abnormalities of the CBC, PT, and/or aPTT are common among patients with bleeding disorders.

If thrombocytopenia is detected, a peripheral blood smear should also be performed to help to rule out pseudothrombocytopenia and to look for abnormal platelet size or appearance, which may indicate a platelet dysfunction disorder. True thrombocytopenia can be caused by a myriad of conditions including systemic disease, infection, drugs, and primary hematologic disorders. The approach to thrombocytopenia is discussed in detail elsewhere. (See "Approach to the child with unexplained thrombocytopenia" and "Diagnostic approach to thrombocytopenia in adults".)

Neutropenia or anemia may indicate underlying systemic disease (eg, malignancy, infection) or a bone marrow disorder (eg, myelodysplasia) and should be evaluated accordingly. Some medications, including antibiotics and anticonvulsants, may cause severe bone marrow injury with subsequent pancytopenia. (See "Diagnostic approach to anemia in adults" and "Clinical manifestations, diagnosis, and classification of myelodysplastic syndromes (MDS)" and "Overview of neutropenia in children and adolescents".)

The PT is used to assess the extrinsic pathway of clotting, which consists of tissue factor and factor VII and coagulation factors in the common pathway (factors II [prothrombin], V, X, and fibrinogen) (figure 2). The aPTT is used to assess the integrity of the intrinsic pathway (prekallikrein, high molecular weight kininogen, factors VIII, IX, XI, XII) as well as the common pathway. Interpretation of abnormal PT and/or aPTT and their associated causes is described in a table (table 3). (See "Clinical use of coagulation tests".)

Some patients may have normal or false-negative test results, especially with Von Willebrand disease or if the disease is mild. Patients with persistent bruising should continue to be followed and may need further testing despite negative test results initially. (See "Clinical presentation and diagnosis of von Willebrand disease" and 'Follow-up and referral' below.)

Tests of platelet function — Measurement of platelet function can be valuable in the evaluation of patients with easy bruising who have normal baseline studies [10]. In our referral hematology practice, we generally order platelet aggregation studies. The clinical use of platelet function tests and management of platelet function disorders is discussed in detail separately. (See "Platelet function testing" and "Inherited platelet function disorders (IPFDs)".)

In addition to studies of platelet aggregation, we will also measure platelet dense granules by electron microscopy if we suspect a platelet function disorder. In the setting of platelet dense granule deficiency, this may be abnormal even when other studies are unremarkable [11].

The bleeding time measures the amount of time required for an incision to stop bleeding. The clinical usefulness of the test, however, is questionable. Bleeding times have been shown to be poorly reproducible and insensitive, and results are subject to numerous factors not related to platelet function [12,13]. We therefore do not feel that the bleeding time has clinical utility as a part of an evaluation for easy bruising.

The Platelet Function Analyzer (PFA-100), a simple and rapid measure of platelet function, may be more sensitive and reproducible than the bleeding time for diagnosing platelet function abnormalities. However, its specificity and sensitivity are limited, and it is not a good screening tool for inherited or acquired platelet disorders [14]. Results are expressed in terms of a normal or elevated (abnormal) “closure time.” Elevated closure times suggest the possibility of a qualitative platelet function defect. Unlike the bleeding time, the PFA-100 allows one to detect aspirin/NSAID-induced platelet dysfunction, which is commonly implicated in patients with an increased bruising tendency. The PFA-100 and other tests of platelet function are discussed in detail elsewhere. (See "Platelet function testing", section on 'PFA-100'.)

Other tests — Mixing studies and factor assays determine if the patient has a clotting factor deficiency or a factor inhibitor. These tests are done when the PT and/or aPTT testing is abnormal. (See "Clinical use of coagulation tests" and "Acquired hemophilia A (and other acquired coagulation factor inhibitors)".)

Additional testing for renal, hepatic, endocrine, or immune dysfunction is indicated only if other symptoms or signs indicate underlying disease.

FOLLOW-UP AND REFERRAL — Reassurance is appropriate for patients with bruising mainly on the distal lower extremities, no other evidence of bleeding, and no personal or family history of significant bleeding. These patients should be followed up with in a few months.

For patients with recent medication exposure known to cause bruising or bleeding (table 2), the clinician should discontinue the culprit medication if possible. After allowing for drug washout and bruise healing (approximately two to four weeks), the clinician should reexamine the patient for evidence of new bruises.

Patients with atypical bruising over the face, trunk, or back should be evaluated for physical abuse. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Physical examination' and "Intimate partner violence: Diagnosis and screening", section on 'Clinical presentation' and "Elder abuse, self-neglect, and related phenomena", section on 'Evaluation and clinical assessment'.)

Patients with any of the following should be referred to a hematologist:

●Continued significant bruising (five or more bruises greater than 1 cm in diameter) without any known trauma

●Personal or family history of abnormal bleeding, especially after surgeries or injuries

●Associated bleeding from other sites (eg, recurrent epistaxis, gingival bleeding, hemarthrosis)

●Abnormal laboratory tests that suggest a bleeding diathesis

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: von Willebrand disease" and "Society guideline links: Acquired bleeding disorders" and "Society guideline links: Rare inherited bleeding disorders".)

SUMMARY AND RECOMMENDATIONS

●The etiology of bruising can be broadly classified into disorders of blood vessels and surrounding tissue, platelet abnormalities, and coagulation disorders (table 1). (See 'Etiology' above.)

●The history and physical examination are initially more useful than laboratory testing in the evaluation of easy bruising. The patient should be asked about associated trauma, location and severity of bruising, bleeding history with previous procedures, medication use, nutrition, and family history. (See 'History' above.)

●The appearance of bruising may assist with diagnosis of the underlying etiology. Bruises should be distinguished from petechiae and purpura, which may also occur with bruising. The presence of other examination findings such as lymphadenopathy or hepatosplenomegaly may also help narrow the diagnosis. (See 'Physical examination' above.)

●Laboratory evaluation for bruising should be considered as an adjunct to performing a good history and physical examination. No laboratory evaluation is generally necessary in patients who meet all of the following criteria:

•Distribution of bruising mainly along distal extremities, especially if associated with trauma

•No other evidence of bleeding (eg, recurrent epistaxis, gingival bleeding, hemarthrosis)

•No personal or family history of significant unexpected bleeding

In all other patients, baseline assays including a complete blood count (CBC) with differential and platelet counts, prothrombin time (PT), and activated partial thromboplastin time (aPTT) should be performed. If these studies are normal, screening for von Willebrand disease is advised. Mixing studies and factor assays determine if the patient has a clotting factor deficiency or a factor inhibitor. These tests are done when the PT and/or aPTT testing is abnormal. (See 'Laboratory testing' above.)

●Measurement of platelet function can be valuable in the evaluation of patients with easy bruising who have normal baseline studies and platelet electron microscopy. In our referral hematology practice, we generally order platelet aggregation studies. The use of a bleeding time is not recommended. (See 'Tests of platelet function' above.)

●Patients with any of the following should be referred to a hematologist (see 'Follow-up and referral' above):

•Continued significant bruising (five or more bruises greater than 1 cm in diameter) without any known trauma

•Personal or family history of abnormal bleeding after surgeries or trauma

•Associated bleeding from other sites (eg, recurrent epistaxis, gingival bleeding, hemarthrosis)

•Abnormal laboratory tests that suggest a bleeding diathesis