Ecchymoses (bruises)
Bruising is a change in skin color that occurs when blood accumulates under the skin when capillaries (small blood vessels) break as a result of a blow or injury – often in the arms and legs. There is no bleeding on the outside of the skin, as long as it remains intact.
Medicines and food supplements
When should you go to the doctor?
Initially, the bruise has a pinkish-red color and after a few hours, it turns black or dark blue, brown, or purple. Within about 2 weeks, often without treatment, the color of the bruise fades, becoming yellow, so that in the end the skin returns to its usual color.
All people can have a bruise at some point in their life, most often when they bump into something. However, older people are more prone to bruising because their skin becomes thinner. In cases of severe trauma, bruises are often unavoidable and are more extensive.
An occasional bruise or a bruise from a minor accident is usually nothing to worry about. Consult your doctor if bruises appear easily, frequently or appear without a specific reason or if they are accompanied by unusual bleeding, such as at the level of the gums. These manifestations can be a side effect of certain drugs (such as anticoagulants, nonsteroidal anti-inflammatory drugs or corticosteroids) or signs of a condition that requires diagnosis and treatment.
The doctor will do tests to rule out a disease that could be the cause of the bruises. If a platelet disorder or another coagulation disorder is suspected, the attending physician will recommend that you be consulted by a hematologist, specialized in the diagnosis and treatment of hematological disorders. If you think that bruising is an adverse effect of a medicine, do not stop taking it and do not change the dose. Instead, talk to the doctor who prescribed the medicine to find the treatment plan that works best in your case.
Most bruises disappear without treatment in about 2 weeks. Applying ice immediately after the injury can minimize bruising. You can prevent minor bruises by taking steps to avoid accidental falls and injuries.
Causes
When you hit a hard object that damages the small vessels (capillaries) in the skin, the body normally responds by forming blood clots to stop the bleeding, which prevents bruising. Sometimes, however, the blood is not able to form clots as it should. When this happens, the blood extravasates from the vessel and you may notice that you bruise.
Bruises are more common among older adults. This is because their skin tends to become thinner as they age. Also, they lose part of the fat layer (adipose tissue) in the skin, which helps protect the blood vessels against injury.
Other reasons for the easy appearance of ecchymoses are the administration of certain drugs or food supplements, coagulation diseases or vitamin deficiency, such as vitamins K and C.
Medicines and food supplements
Certain medications can contribute to easy bruising by decreasing the blood’s ability to coagulate (to form a blood clot when the vessel wall breaks and thus stop the bleeding). These drugs are often used to prevent acute myocardial infarction and stroke. Your doctor may also prescribe these medicines if you have atrial fibrillation, deep vein thrombosis (DVT) or pulmonary thromboembolism (PET) or have recently had a heart stent fitted for coronary artery disease.
Examples of such drugs are:
- Anticoagulant drugs: warfarin, heparin, dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis)
- Antiplatelet drugs: clopidogrel (PLAVIX), prasugrel (Efient) and ticagrelor (Brilique)
- Nonsteroidal anti-inflammatory drugs (NSAIDs): aspirin, ibuprofen, naproxen, celecoxib
- Some antibiotics, such as ampicillin and vancomycin
Also, certain herbs and food supplements can increase the risk of bruising due to a blood-thinning effect, although studies proving these effects are limited in the specialized literature. Some examples are:
- Ginkgo biloba
- Ginseng
- Fish oil
- Garlic
- Rattle
If you take these medicines or dietary supplements, it is possible that the bleeding in the skin may take longer than usual to stop. This allows enough blood to leak under the skin to cause a bruise.
Diseases
If bruising occurs easily, impaired ability to form blood clots to stop bleeding may be the result of an underlying condition. The formation of blood clots depends on a good diet, a healthy liver and a healthy bone marrow. If any of these factors are out of balance, bruising can easily occur.
Examples of coagulation disorders and conditions that favor the appearance of ecchymoses are:
Hemophilia A
Hemophilia A is also known as classic hemophilia or coagulation factor VIII (FVIII) deficiency.
It is usually inherited. The gene that determines the absence or deficiency of coagulation factor VIII is present on the sex chromosome X and is transmitted autosomal recessively.
Autosomal recessive transmission means that a patient will have the disease only if the mutation is present on both copies of the involved gene. If there is only one copy, the person will be the bearer.
Women inherit two X (XX) chromosomes, one from the mother and one from the father. Men inherit an X chromosome from their mother and a Y chromosome from their father (XY). This means that if a son inherits the hemophilia X chromosome from his mother, he will have hemophilia. And it also means that fathers cannot genetically transmit hemophilia to their sons, because the son can only inherit the Y chromosome from the father. However, because daughters have two X chromosomes, even if they inherit the hemophilia gene from the mother, they will most likely inherit a healthy X chromosome from the father and they will not have hemophilia. A daughter who inherits an X chromosome that contains the hemophilia gene is called a carrier. She can pass the gene on to her children. Hemophilia also occurs in girls, but the cases are rare.
Hemophilia B
Hemophilia B is called factor IX deficiency (FIX) or Christmas disease.
Like hemophilia A, this disease is also caused by a genetic mutation located on the X chromosome that causes the lack or deficiency of factor IX, a coagulation protein.
Von Willebrand’s disease
Von Willebrand disease is caused by a genetic mutation that results in a deficiency of a protein known as von Willebrand factor (vWF). This is a type of protein that helps blood coagulation with a very important role in the adhesion of platelets in the first stages of coagulation, when the platelet clot is formed.
Von Willebrand disease is the most common inherited hemorrhagic disorder, with a prevalence of 1% in the general population.
Many patients with von Willebrand’s disease do not know that they suffer from this condition, because the signs are mild or absent. The most common sign of the condition is abnormal bleeding.
Thrombocytopenia (low number of platelets)
Thrombocytopenia is considered if the number of platelets is < 150,000/ microL of blood.
There are many causes of a decrease in the number of platelets. Some causes involve decreased production of platelets in the bone marrow, and others cause destruction or increased loss of platelets.
A low number of platelets means that a blood clot cannot form and in the event of an injury you have an increased risk of bleeding that is difficult to stop and the formation of ecchymoses (bruises). A very low number of platelets can cause excessive blood loss or internal bleeding, which could be life-threatening. You may need medical treatment.
Cushing’s syndrome and disease (hypercorticism)
The increased concentration of cortisol for a long period of time can cause a medical condition called Cushing’s syndrome. The cause can be a condition or tumor located in the adrenal glands (adrenal cortical adenoma) or a pituitary tumor that produces an excess of cortisol through inadequate ACTH secretion (in this case, the condition is called Cushing’s disease).
Skin changes may occur (thin, fragile skin that can be easily injured, with bruises and blue stretch marks).
Ehlers-Danlos syndrome
Ehlers-Danlos syndrome represents a heterogeneous group of rare genetic diseases in which an abnormality of the connective tissue occurs.
The skin is very fragile, supple, hyperextensible, sensitive to the smallest blows, which cause extensive wounds, which are difficult to heal. Bruises and hematomas are numerous and can appear spontaneously or are caused by minor blows. There are no coagulation disorders.
Vitamin K and C deficiency
Deficiencies in vitamins that help blood clot, such as vitamin K and vitamin C, can also contribute to easy bruising. Being malnourished can increase the chance of being deficient in essential vitamins and nutrients.
The doctor can recommend blood tests to check the level of these vitamins (vitamin K and vitamin C) and can recommend vitamin supplements depending on the result.
Age
Bruises that appear easily are common at older ages.
The condition is called senile purpura and is more common in women. As people age, their skin becomes thinner and drier and loses part of the protective fatty layer that helps cushion the blood vessels at the time of a blow or trauma. Bruises appear more frequently on the thighs, buttocks and upper limbs, on the arms or the back of the hand. However, these people have no other signs of excessive bleeding, and the blood test results are normal.
Most bruises in the elderly are harmless and disappear without treatment.
However, bruising in the elderly can also occur because they frequently take blood-thinning medications, such as aspirin, clopidogrel or warfarin, which increases the risk of bleeding and bruising.
Signs and symptoms
The name “ecchymosis” derives from the Greek word “ekkhumÅsis” which means “escape of blood”. In the case of ecchymosis, the blood “escapes” from the damaged blood vessels and infiltrates the surrounding tissue, causing the characteristic color change.
The bruise first starts as a pink-red spot and within a few hours (1-2 days) it changes to dark blue or purple, and after a few days it fades to purple, green, dark yellow and finally turns yellow pale until it disappears completely. Usually, a bruise will heal completely in 2 weeks.
This color change is due to the biochemical degradation of hemoglobin (the iron-rich protein that carries oxygen in red blood cells). The final degradation products of hemoglobin are biliverdin and bilirubin, which are green and yellow pigments, respectively.
Bruises are frequently 1 centimeter or larger, and the person may occasionally experience pain and subsequent swelling around the injury. In addition, the area may be sensitive to touch. Bruises are common on the arms and legs, as these are the areas most likely to be injured. Bruising can also occur when you suffer a sprain or dislocation, especially at the wrist or ankle. Older adults may notice painless bruising on the forearms and backs of the hands.
Similar medical conditions
Besides ecchymosis, there are 2 other types of bleeding under the skin. You can usually tell what type of bleeding you have by looking at the size, location, and severity of the colored spot.
Purple zones
Purple zones are dark purple spots with a diameter between 4-10 millimeters (smaller than ecchymosis). It tends to have a more defined border than an ecchymosis and sometimes looks more like a rash than a bruise. Unlike ecchymosis, purpura is not caused by the impact on the capillaries due to an injury. Instead, purpura is usually caused by an infection (HIV, Epstein-Barr virus hepatitis, rubella), certain medications that affect the number or function of platelets, or blood clotting disorders.
Petechiae
Petechiae are very small, round spots on the skin that can be purple, red or brown. They are point-shaped and have dimensions smaller than 2 mm and are usually flat. In general, petechiae are smaller versions of purpura. It is formed when the capillaries break and blood flows that accumulates under the skin. They are caused by broken capillaries and appear in groups. Similar to purpura, petechiae change color as the accumulated blood breaks down. The color changes from reddish-purple to brown, orange, blue or green. These spots do not fade or change color if pressure is applied to them. Petechiae may appear around or among purpura spots. Petechiae are common and can indicate a number of conditions, from minor to very serious.
When should you go to the doctor?
Sometimes easy bruising indicates a serious underlying condition, such as a blood clotting disorder or another condition. Go to a doctor’s consultation if:
- You have frequent, large bruises, especially if the bruises appear on the trunk, back or face or appear for no reason
- You bruise easily and have a history of excessive or prolonged bleeding, such as after a minor cut or during a surgical procedure
- The bruises appeared suddenly, especially if you recently started taking a new medicine.
- You have a family medical history of bruising or coagulation disorders
- You have a very painful swelling in the bruised area which may be a sign of a hematoma (collection of blood)
- The bruise lasts more than 2 weeks
- Bruising tends to appear in the same area
- You notice unusual bleeding, such as from the nose (epistaxis), blood in the urine (hematuria) or in the stool (faeces)
- You still have pain after 3 days in the case of an apparently minor injury
These situations may indicate:
- A low level of certain blood cells (platelets) that play an essential role in the formation of a blood clot after a wound or trauma
- Abnormal functioning of platelets
- Disorders of some proteins that help to form a blood clot, called coagulation factors
Another serious cause of bruising is family violence. If a close person has bruises that cannot be explained, especially in an unusual area, such as on the face, consider the possibility of physical abuse.
Diagnostic
To find the cause of the bruises, the doctor will perform a physical examination and ask you a series of questions about your symptoms and your and your family’s medical history.
He also recommends performing a blood count test, a routine blood test that provides information about the number of platelets in the blood, as well as some coagulation tests that check how well the blood coagulates, such as the Quick prothrombin time (INR) and activated partial thromboplastin time (aPTTP). These tests are considered screening tests. If one of these tests shows a change, additional tests and investigations are usually needed to identify the cause of the clotting disorder.
If a platelet disorder or a coagulation disorder is suspected, the attending physician will recommend that you be consulted by a hematologist, who is a doctor specialized in the diagnosis and treatment of hematological disorders.
The following questions can help you talk to your doctor about your problem:
- What caused the bruising?
- Why am I prone to bruises?
- Should I have blood tests to see if a medical condition is the cause of the bruising?
- What measures can I take to reduce my risk of bruising?
- Should I pay attention to certain signs that indicate a complication?
Treatment
Once a bruise has formed, not much can be done to treat it.
Most bruises fade in 2 weeks without treatment, as the body reabsorbs the blood extravasated to the skin, although healing may take longer as you age. More severe bruises and hematomas can take a month or even longer to heal.
The following simple recommendations can improve the healing of the bruise:
- Elevate the bruised area above the level of the heart, if possible
- In the first 1-2 days after the injury, apply an ice pack wrapped in a thin towel to the bruised area for 20 minutes. Repeat several times a day. This helps reduce swelling and pain
- If the bruised area swells, put an elastic bandage around it, but do not tie it too tightly
- If the skin is not injured, you do not need to bandage the bruise. If necessary, you can take paracetamol for pain
Prognosis
Bruises can be unsightly, but most heal without treatment. However, bruises can be a sign of a platelet disorder or another clotting disorder, so if you have large, frequent or unexplained bruising, see a doctor.
Prevention
Although certain conditions and medications increase the risk of bruising easily, it is possible to prevent their occurrence.
One method is to take extra care as you get older. The skin in older adults is generally thinner, which can increase the risk of bruising.
Talk to your doctor about any medication that can cause bleeding and bruising. The doctor can adjust the treatment plan. Never decide on your own to stop taking the prescribed medication. Some medications may require a gradual reduction and careful monitoring.
Make sure you have a healthy, balanced diet that provides you with a sufficient amount of vitamins K and C:
- Vitamin K (phylloquinone or menadione) is an essential vitamin, which cannot be produced in the human body, which plays a vital role in the production of coagulation factors. The natural form is found in green vegetables (broccoli and spinach), green tea and soybean, cottonseed, canola and olive oils. Small amounts are found in meat and dairy products. The recommended daily dose for adults is 120 mcg (micrograms) for men and 90 mcg (micrograms) for women. You should be able to get the full amount of vitamin K you need from your diet.
- Vitamin C (ascorbic acid). Vitamin C is also an essential vitamin that is available in a wide range of foods. It is found in a variety of vegetables and fruits. Citrus fruits (oranges, lemons) are the best-known sources of vitamin C, but it is also found in other fruits (blackcurrants, strawberries, guava, kiwi, papaya) and vegetables, such as bell peppers, tomatoes, potatoes, carrots, broccoli, cabbage, spinach, greens, as well as in milk and some types of meat (oysters, kidneys, liver, fish). The recommended daily dose for adults is 90 mg for men and 75 mg for women. You should be able to get all the necessary amount of vitamin C from your daily diet.
Take measures to avoid accidental falls and injuries:
- Use good lighting throughout the house. Keep a night light in the bedroom or bathroom. Use the flashlight of your mobile phone or attach a small flashlight to your keys, so that you can see in poorly lit areas around the house or apartment
- Check your vision. Even a slight decrease in vision can increase the risk of falling
- Avoid clutter and do not use carpets, especially on the stairs
- Hold on to the railing when going up or down the stairs
- Arrange the furniture and electrical cables so that you are not hindered by them
- Read the leaflet and ask the doctor about the side effects of the medicines you are taking Tell your doctor if the prescribed medicine makes you feel dizzy or drowsy
- Improve your sense of balance by practicing balance exercises
- Wear protective equipment such as a helmet and pads when playing contact sports or riding a bicycle or motorcycle
