At one time or another everyone will notice a bruise and think where did I get that? Sometimes they can be fairly significant and you think, how did I not feel that? What causes that, should you be concerned, and should they be investigated? How do I classify that black and blue mark?
A bruise is defined as discolored skin that is caused by some trauma, bump, or impact that has ruptured small blood vessels. A hematoma is a swelling of clotted blood within the body's tissues, while ecchymosis is a skin discoloration resulting in bleeding beneath the skin and is larger than 1 cm. Petechiae are small purple, red or brown spots due to blood vessel breakage and purpura are purple spots due to small vessel bleeding. Skin discoloration occurs without trauma and considered to be ecchymosis as opposed to hematoma which depend on size and location.(1)
Hematomas can result from invasive procedures and injections of medications. They may also appear spontaneously without identifiable cause. Anticoagulation can increase the risk of hematoma formation.
A list of medications causing excess bleeding include:
- warfarin (Coumadin),
- clopidogrel (Plavix),
- aspirin-containing products (Alka Seltzer),
- dipyridamole (Persantine),
- vitamin E,
- NSAIDs, for example, ibuprofen, Motrin, Advil, Aleve,
- garlic supplements, and
- Ginkgo biloba.(2)
Vascular structure and function
Endothelial cells play a key role in hemostasis. As a procoagulant role they induce activation of the coagulation cascade, platelet adhesion and as an anticoagulation role they prevent platelet activation. When the endothelial lining is disrupted, the vascular system acts to prevent bleeding and promotes rapid vasoconstriction of the injured vessels and enhances contact activation of platelets with coagulation factors.(3)
There are both hereditary and acquired defects of the vascular system. Vascular malformations in which the blood vessels lack capillaries between the artery and the vein causing them to be fragile and rupture easily are found in cavernous hemangioma (Kassabach-Merritt syndrome) and hereditary hemorrhagic telangiectasia (Rendu-Osler).(4)
Connective tissue disorders are seen in patients with Marfan disorder in which patients present with long limbs and a predisposition to cardiovascular disease. Ehlers-Danlos syndrome is caused by abnormalities in the structure, production and of the processing of collagen. Symptoms vary and range from mildly loose joints to life-threatening complications. Features include joint hypermobility and highly elastic skin that bruises easily.(5)
Acquired defects include disorders caused by an underlying disease or condition that decreases the supportive connective tissue in the blood vessel wall as seen in senile pupura, Cushing syndrome and corticosteroid therapy, scurvy, Henoch-Schonlein purpura, drugs and amyloidosis.(4)
Skin Bleeding and Platelets
Platelets are the initial response in trauma and the prevention of bleeding. Platelets can be decreased in number (thrombocytopenia) or lacking function and result in skin petechiae and purpura or more severe mucosal bleeding, GI bleeding and ICH. In patients with immune thrombocytopenia (ITP) a correlation in bleeding and platelet count below 20 × 109/L. Skin bleeding increased linearly with thrombocytopenia within a platelet count range of 0-50 × 109/L. Whereas mucosal and organ bleeding increases below a platelet count of 10 to 15 × 109/L.(6)
Von Willebrand disease is a common inherited bleeding disorder that is caused by a qualitative or quantitative deficiency of VWF which is a plasma protein that mediates the initial adhesion of platelets at the site of vascular injury and stabilizes circulating FVIII. A defect can result in impairing platelet function or FVIII activity. Clinical manifestations include mucous membranes and skin sites, bleeding can be mild to moderate severity. Ecchymosis is seen in 11.9-50% of healthy individuals versus 49-50% of all patients diagnosed with von Willebrand disease.(7)
There are several reasons for that colorful and sometimes painful skin manifestation. It can be a complication due to a vascular disorder, platelets, medication, congenital or acquired disorder, or just an unexplained bump! It is important to pay attention if the bruises are extensive and frequent and should be followed up by an evaluation for possible bleeding disorder.
- Davis, CP., Cunha, JP., Hematoma vs. Ecchymosis: Differences and Similarities, Hematoma vs. Ecchymosis: Are They the Same Thing? (emedicinehealth.com),
Reviewed on 4/9/2020
- Nabili, SN., Stoppler, MC., Hematoma: Types, Symptoms, Pictures, Causes and Treatments, Hematoma: Types, Symptoms, Pictures, Causes & Treatments (rxlist.com)
- Kakali Ghoshal and Maitree Bhattacharyya, (2014). Overview of Platelet Physiology: Its Hemostatic and Nonhemostatic Role in Disease Pathogenesis,
The Scientific World Journal,2014:16.
- Arrieta-Blanco, J. J., Oñate-Sánchez, R., Martínez-López, F., Oñate-Cabrerizo, D., & Cabrerizo-Merino, M. D. (2013). Inherited, congenital and acquired disorders by hemostasis (vascular, platelet & plasmatic phases) with repercussions in the therapeutic oral sphere.
Medicina oral, patologia oral y cirugia bucal, 19:280-8
- Defendi GL. Genetics of Ehlers-Danlos Syndrome.
Medscape Reference. August, 2015; http://emedicine.medscape.com/article/943567-overview
- Takaaki Hato, Naoki Shimada, Yoshiyuki Kurata, Masataka Kuwana, Kingo Fujimura, Hirokazu Kashiwagi, Toshiro Takafuta, Mitsuru Murata, Yoshiaki Tomiyama; Risk factors for skin, mucosal, and organ bleeding in adults with primary ITP: a nationwide study in Japan.
Blood Adv2020; 4 (8): 1648–1655.
- The Diagnosis, Evaluation, and Management of VWD, National Heart Lung and Blood institute, December 2007.