Evaluation of easy bruising

Diseases

Summary

A bruise (ecchymosis) is caused by bleeding beneath the skin as a result of extravasation of blood from surrounding blood vessels. It may develop due to abnormalities in hemostasis or alteration in the structural integrity of the blood vessel wall and surrounding subcutaneous tissue.

Easy bruising implies that no significant trauma has occurred to the skin or soft tissue to cause the bruise, and the bruises are larger and/or more frequent than what would normally be seen. It is a common complaint of patients seen in a medical practice. Surveys of normal healthy individuals report the frequency of easy bruising to range from 12% to 55%.[1] [2]

Causes vary from those with no significant clinical consequence to underlying diseases that could be life-threatening such as severe bleeding disorders or bone marrow malignancies. Appropriate evaluation is crucial in reaching the correct diagnosis and treatment; therefore, a structured approach that incorporates the history, physical exam, and laboratory studies should be utilized. However, laboratory testing is costly and results can be confusing and require an experienced physician for proper interpretation.

Referral to a hematologist for further evaluation may be needed. Appropriate evaluation is especially important before invasive procedures.

Library

Large bruise on the abdomen of a patient on warfarin with acquired factor V inhibitor
Bruising affecting the thigh and pelvic area in a patient with vitamin C deficiency
Bruising in patient with vasculitis (drug-induced)
Diagnostic algorithm for the workup of easy bruising (*Test usually not ordered in the US)

Citations

Key Articles

Faughnan ME, Mager JJ, Hetts SW, et al. Second international guidelines for the diagnosis and management of hereditary hemorrhagic telangiectasia. Ann Intern Med. 2020 Dec 15;173(12):989-1001.[Abstract][Full Text]
Tiede A, Collins P, Knoebl P, et al. International recommendations on the diagnosis and treatment of acquired hemophilia A. Haematologica. 2020 Jul;105(7):1791-801.[Abstract][Full Text]
Neunert C, Terrell DR, Arnold DM, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019 Dec 10;3(23):3829-66.[Abstract][Full Text]
Rodeghiero F, Tosetto A, Abshire T, et al. ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. J Thromb Haemost. 2010;8:2063-2065.[Abstract][Full Text]
Platton S, Baker P, Bowyer A, et al. Guideline for laboratory diagnosis and monitoring of von Willebrand disease: a joint guideline from the United Kingdom Haemophilia Centre Doctors' Organisation and the British Society for Haematology. Br J Haematol. 2024 May;204(5):1714-31.[Full Text]

Other Online Resources

University of Oklahoma Health Sciences Center: platelets on the web - drug-induced thrombocytopenia
International Society on Thrombosis and Haemostasis: bleeding assessment tool

Referenced Articles

1. Srámek A, Eikenboom JC, Briët E, et al. Usefulness of patient interview in bleeding disorders. Arch Intern Med. 1995;155:1409-1415.[Abstract]
2. Mauer AC, Khazanov NA, Levenkova N, et al. Impact of sex, age, race, ethnicity and aspirin use on bleeding symptoms in healthy adults. J Thromb Haemost. 2011;9:100-108.[Abstract][Full Text]
3. Faughnan ME, Mager JJ, Hetts SW, et al. Second international guidelines for the diagnosis and management of hereditary hemorrhagic telangiectasia. Ann Intern Med. 2020 Dec 15;173(12):989-1001.[Abstract][Full Text]
4. Li Y, Dong S, Wang P, et al. Influence of low-molecular-weight heparin injection sites on local bruising and pain: a systematic review and meta-analysis. J Clin Pharm Ther. 2021 Jun;46(3):688-97.[Abstract]
5. Kimble LP, Momary KM, Adewuyi M. A qualitative study of nuisance bleeding and medication-related beliefs with dual antiplatelet drug therapy. Heart Lung. 2018 Sep-Oct;47(5):485-8.[Abstract]
6. Johnson S, Katyal N, Narula N, et al. Adverse side effects associated with corticosteroid therapy: a study in 39 patients with generalized myasthenia gravis. Med Sci Monit. 2021 Oct 28;27:e933296.[Abstract][Full Text]
7. Guillot B. Adverse skin reactions to inhaled corticosteroids. Expert Opin Drug Saf. 2002 Nov;1(4):325-9.[Abstract]
8. Krasowska D, Szymanek M, Schwartz RA, et al. Cutaneous effects of the most commonly used antidepressant medication, the selective serotonin reuptake inhibitors. J Am Acad Dermatol. 2007 May;56(5):848-53.[Abstract]
9. Pai VB, Kelly MW. Bruising associated with the use of fluoxetine. Ann Pharmacother. 1996 Jul-Aug;30(7-8):786-8.[Abstract]
10. Bolton-Maggs PH, Chalmers EA, Collins PW, et al. A review of inherited platelet disorders with guidelines for their management on behalf of the UKHCDO. Br J Haematol. 2006;135:603-633.[Abstract][Full Text]
11. Balduini CL, Cattaneo M, Fabris F, et al. Inherited thrombocytopenias: a proposed diagnostic algorithm from the Italian Gruppo di Studio delle Piastrine. Haematologica. 2003;88:582-592.[Abstract]
12. Dawood BB, Lowe GC, Lordkipanidzé M, et al. Evaluation of participants with suspected heritable platelet function disorders including recommendation and validation of a streamlined agonist panel. Blood. 2012;120:5041-5049.[Abstract][Full Text]
13. Connell NT, Flood VH, Brignardello-Petersen R, et al. ASH ISTH NHF WFH 2021 guidelines on the management of von Willebrand disease. Blood Adv. 2021 Jan 12;5(1):301-25.[Abstract][Full Text]
14. Mumford AD, Ackroyd S, Alikhan R, et al. Guideline for the diagnosis and management of the rare coagulation disorders: a United Kingdom Haemophilia Centre Doctors' Organization guideline on behalf of the British Committee for Standards in Haematology. Br J Haematol. 2014;167:304-326.[Abstract][Full Text]
15. Franchini M, Mannucci PM. Acquired haemophilia A: a 2013 update. Thromb Haemost. 2013; 110(06): 1114-20.[Abstract]
16. Collins P, Chalmers E, Hart D, et al. Diagnosis and management of acquired coagulation inhibitors: a guideline from UKHCDO. Br J Haematol. 2013;162:758-773.[Abstract][Full Text]
17. Ivanov OL, Lvov AN, Michenko AV, et al. Autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome): review of the literature. J Eur Acad Dermatol Venereol. 2009;23:499-504.[Abstract]
18. George JN. How I treat patients with thrombotic thrombocytopenic purpura: 2010. Blood. 2010;116:4060-4069.[Abstract][Full Text]
19. Kempton CL, White GC 2nd. How we treat a hemophilia A patient with a factor VIII inhibitor. Blood. 2009;113:11-17.[Abstract][Full Text]
20. Tiede A, Rand JH, Budde U, et al. How I treat the acquired von Willebrand syndrome. Blood. 2011;117:6777-6785.[Abstract][Full Text]
21. Tiede A, Collins P, Knoebl P, et al. International recommendations on the diagnosis and treatment of acquired hemophilia A. Haematologica. 2020 Jul;105(7):1791-801.[Abstract][Full Text]
22. Lakshmanan S, Cuker A. Contemporary management of primary immune thrombocytopenia in adults. J Thromb Haemost. 2012;10:1988-1998.[Abstract][Full Text]
23. George JN. Sequence of treatments for adults with primary immune thrombocytopenia. Am J Hematol. 2012;87(suppl 1):S12-S15.[Abstract][Full Text]
24. Neunert C, Terrell DR, Arnold DM, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019 Dec 10;3(23):3829-66.[Abstract][Full Text]
25. Kuter DJ, Bussel JB, Lyons RM, et al. Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet. 2008;371:395-403.[Abstract]
26. Bussel JB, Provan D, Shamsi T, et al. Effect of eltrombopag on platelet counts and bleeding during treatment of chronic idiopathic thrombocytopenic purpura: a randomised, double-blind, placebo-controlled trial. Lancet. 2009;373:641-648.[Abstract]
27. Rodeghiero F, Stasi R, Gernsheimer T, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009;113:2386-2393.[Abstract][Full Text]
28. Ng C, Motto DG, Di Paola J. Diagnostic approach to von Willebrand disease. Blood. 2015 Mar 26;125(13):2029-37.[Full Text]
29. Rodeghiero F, Tosetto A, Abshire T, et al. ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. J Thromb Haemost. 2010;8:2063-2065.[Abstract][Full Text]
30. Acosta M, Edwards R, Jaffee IM, et al. A practical approach to pediatric patients referred with an abnormal coagulation profile. Arch Pathol Lab Med. 2005 Aug;129(8):1011-6.[Abstract][Full Text]
31. Elbatarny M, Mollah S, Grabell J, et al. Normal range of bleeding scores for the ISTH-BAT: adult and pediatric data from the merging project. Haemophilia. 2014;20:831-835.[Abstract][Full Text]
32. Kumar V, Abbas AK, Fausto N, et al (eds). Robbins basic pathology (8th ed.). Philadelphia, PA:Saunders/Elsevier;2007:10-11.
33. Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome. J Bone Joint Surg Br. 1969;51:444-453.[Abstract][Full Text]
34. Platton S, Baker P, Bowyer A, et al. Guideline for laboratory diagnosis and monitoring of von Willebrand disease: a joint guideline from the United Kingdom Haemophilia Centre Doctors' Organisation and the British Society for Haematology. Br J Haematol. 2024 May;204(5):1714-31.[Full Text]
35. Kalot MA, Husainat N, El Alayli A, et al. von Willebrand factor levels in the diagnosis of von Willebrand disease: a systematic review and meta-analysis. Blood Adv. 2022 Jan 11;6(1):62-71.[Abstract][Full Text]
36. Koscielny J, Kiesewetter H, von Tempelhoff GF. More on: platelet function analyzer (PFA)-100 closure time in the evaluation of platelet disorders and platelet function. J Thromb Haemost. 2006;4:1426-1427.[Abstract][Full Text]
37. Harrison P, Robinson M, Liesner R, et al. The PFA-100: a potential rapid screening tool for the assessment of platelet dysfunction. Clin Lab Haematol. 2002;24:225-232.[Abstract]
38. Breen KA, Grimwade D, Hunt BJ. The pathogenesis and management of the coagulopathy of acute promyelocytic leukaemia. Br J Haematol. 2012;156(1):24-36.[Abstract][Full Text]
39. Ghali N, Sobey G, Burrows N. Ehlers-Danlos syndromes. BMJ. 2019 Sep 18;366:l4966.[Abstract]