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Child health Haematology Skin and nail

Bruising

Last revised in March 2026

A bruise is a haematoma which forms due to bleeding under intact skin into subcutaneous tissue, due to vascular damage or injury

Bruising: Summary

  • A bruise (ecchymosis) is a haematoma that forms due to bleeding under intact skin into subcutaneous tissue, caused by vascular damage or injury leading to extravasation of blood from surrounding blood vessels.
    • 'Easy bruising' implies that no significant trauma has occurred to the skin or subcutaneous tissue, and bruises are larger and/or occur more frequently than would normally be expected.
  • Possible causes vary from the clinically insignificant to potentially serious and life-threatening, and include:
    • Trauma — which may be accidental or non-accidental.
    • Vascular — including senile purpura, purpura simplex, and connective tissue disorders.
    • Platelet disorders — including primary immune thrombocytopenic purpura, aplastic anaemia, and haematological malignancy.
    • Coagulation disorders — including haemophilia, von Willebrand disease, and vitamin K deficiency.
    • Drugs — such as corticosteroids, antiplatelets, anticoagulants, and nonsteroidal anti-inflammatory drugs.  
  • The presence of a bleeding disorder or other underlying medical condition does not rule out non-accidental injury as a cause of bruising.
  • Assessment of a person with easy or unexplained bruising involves:
    • Asking about any trauma; symptoms suggesting an underlying platelet or coagulation disorder such as mucocutaneous bleeding, excessive or prolonged bleeding; underlying medical causes; medications and alcohol intake; and family history.
    • Assessing the location and pattern of bruising in the context of the person's age, mobility, developmental status, any explanation for injury, and any red flags for non-accidental injury.
    • Examining for clinical features of an underlying cause.
  • Investigation of an adult with unexplained bruising or bleeding includes:
    • Arranging a full blood count (FBC) and blood film (the urgency depending on clinical judgement), coagulation screen, and tests for liver, renal, and thyroid function.
  • Investigation of a child or young person with unexplained bruising or bleeding includes:
    • Arranging a FBC and blood film (the urgency depending on clinical judgement) and coagulation screen.
  • FBC and coagulation screen may be normal in people with mild coagulation and platelet function disorders. 
  • Management of a person with unexplained bruising or bleeding includes:
    • Advising emergency department assessment and management if there is significant or progressive active bleeding.
    • Referring immediately to local child or adult social care or the police if there is suspected non-accidental injury.
    • Referring children and young people for immediate assessment for suspected leukaemia if there is unexplained petechiae, hepatosplenomegaly, or a suggestive FBC result.
    • Referring children with periorbital bruising for immediate assessment (within 48 hours) for suspected neuroblastoma if there is a palpable abdominal mass or abdominal organomegaly.
    • Liaising with a paediatrician or paediatric haematologist for further assessment of other children, depending on clinical judgement.
    • Referring adults for immediate assessment for suspected leukaemia if there is a suggestive FBC result.
    • Referring other adults to a haematologist or seeking specialist advice if there is thrombocytopenia; an abnormal coagulation screen or uncertainty in the interpretation of results; or normal blood results but a bleeding disorder is still suspected, depending on clinical judgement.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the assessment and management of easy or unexplained bruising in children and adults.

This CKS topic does not cover the assessment or management of other types of purpura, or the detailed management of underlying causes of abnormal bruising.

There are separate CKS topics on Child maltreatment - recognition and management, Domestic abuse, Falls - risk assessment, Haematological cancers - recognition and referral, and Platelets - abnormal counts and cancer.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

March 2026 — reviewed. A literature search was conducted in February 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has been updated in line with current evidence in the literature. No major changes to the recommendations have been made.

Previous changes

March 2021 — reviewed. A literature search was conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

March 2016 — reviewed. A literature search was conducted in February 2016 to identify evidence-based guidelines, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to recommendations have been made, but additional emphasis has been put on vulnerable adults with possible safeguarding issues, such as the elderly.

December to March 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 February 2026.

HTAs (Health Technology Assessments)

No new HTAs since 1 February 2026.

Economic appraisals

No new economic appraisals relevant to England since 1 February 2026.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 February 2026.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 February 2026.

New policies

No new national policies or guidelines since 1 February 2026.

New safety alerts

No new safety alerts since 1 February 2026.

Changes in product availability

No changes in product availability since 1 February 2026.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Differentiate normal and abnormal bruising.
  • Arrange appropriate investigations where necessary.
  • Identify red flags for possible non-accidental injury, and manage appropriately.
  • Admit or refer people with abnormal bruising, if clinically appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • A bruise (ecchymosis) is a haematoma that forms due to bleeding under intact skin into subcutaneous tissue, caused by vascular damage or injury leading to extravasation of blood from surrounding blood vessels [Ward et al, 2013; Hughes, 2024].
    • A RCPCH systematic review on bruising cites study evidence that, in general, red, blue, and purple colours were more commonly seen in bruises less than 48 hours old, while brown and green bruises were most often seen in bruises over seven days old. This is not always the case. The colour of a bruise is not a reliable indicator of the age of a bruise, and there is a wide variability in the appearance and healing of bruises, both between people and among bruises on the same person  [RCPCH, 2020].
  • 'Easy bruising' implies that no significant trauma has occurred to the skin or subcutaneous tissue, and bruises are larger and/or occur more frequently than would normally be expected.

What causes it?

Bruising may develop due to abnormalities in haemostasis or alteration in the structural integrity of the blood vessel wall and surrounding subcutaneous tissue. Possible causes vary from the clinically insignificant to potentially serious and life-threatening, such as severe bleeding disorders or bone marrow malignancy [Biss, 2022].

Trauma

  • Bruising usually occurs as a result of trauma, which may be caused by:
    • Accidental injury (which may or may not be recalled by the person or their carer) [Anderson, 2010; RCPCH, 2020; Biss, 2022].
      • Bruises from accidental trauma are typically distributed over the bony prominences of the legs, such as the anterior tibia and knee, and the front of the face in a T-shaped distribution involving the forehead, nose, upper lip, and chin.
      • The number of bruises a child sustains through normal activity increases as they get older and their level of independent mobility increases.
    • Non-accidental injury — see the section on Red flags for non-accidental injury for more information. This may include [Carpenter, 2022; Home Office, 2023; Hughes, 2024]:

Vascular and systemic disorders

  •  Vascular and systemic disorders leading to easy bruising include:
    • Senile purpura [Harrison, 2017] [Hughes, 2024] 
      • A common and benign condition, resulting from impaired collagen production and capillary fragility in elderly people.
      • Often causes bilateral dark bruising on the dorsum of the hands and extensor surfaces of the forearms and shins, which typically fades to a brownish colour over several months.
    • Purpura simplex [Harrison, 2017] [Hughes, 2024] 
      • A benign disorder often occurring in otherwise healthy young women in their twenties or thirties.
      • Often causes bruising on exposed areas such as the arms or upper thighs after minor or inadvertent trauma, and may be associated with heavy menstrual bleeding.
    • Hereditary haemorrhagic telangiectasia (HHT) [Hughes, 2024]  
      • A rare autosomal dominant genetic condition that leads to mucocutaneous telangiectasia of the skin, oral mucosa, and nasal cavity. There may be a positive family history, recurrent nosebleeds, fatigue, nail changes, and hair loss.
    • Hypothyroidism [Harrison, 2017] 
      • This may affect clotting factors and blood vessel integrity. See the CKS topic on Hypothyroidism for more information.
    • Cushing's syndrome [Harrison, 2017] [Biss, 2022] [Hughes, 2024] 
      • May present with facial plethora, hirsutism, hyperglycaemia, hypertension, and striae.
    • Ehlers-Danlos syndrome [Anderson, 2010] [Biss, 2022] [Carpenter, 2022] [Hughes, 2024]
      • This causes mutations in collagen production, joint hypermobility, skin translucency and skin hyperextensibility. It has an estimated prevalence of 1 in 2500–5000 and causes abnormalities in capillary structure and deficiencies of perivascular collagen, leading to vascular fragility and possible rupture when subject to shearing forces.
      • It may present with gum bleeding, prolonged bleeding after surgery, heavy menstrual bleeding, atrophic scarring, and a history of joint dislocations.
    • Osteogenesis imperfecta [Anderson, 2010] [Biss, 2022] [Carpenter, 2022]  
      • This is characterized by blue sclerae, short stature, bone fragility, dentinogenesis imperfecta, and adult hearing loss.
      • Easy bruising after minimal or no trauma is thought to occur due to platelet dysfunction and capillary fragility. It has an estimated prevalence of 6–7 in 100,000 and is generally inherited as an autosomal dominant condition.
    • Vitamin C deficiency (scurvy) [Anderson, 2010] [Harrison, 2017] [Anderst, 2022] [Hughes, 2024]
      • This may lead to defects in collagen and blood vessel integrity, presenting with malaise, perifollicular haemorrhage and bruising, gum bleeding, tooth loss, impaired wound healing, and/or coiled hairs.

Platelet disorders

  •  Platelet disorders leading to easy bruising include:
    • Thrombocytopenia due to increased platelet destruction [Anderson, 2010] [Carpenter, 2022] 
      • Primary immune thrombocytopenic purpura (ITP) — this is an acquired immune-mediated disorder and is a diagnosis of exclusion, characterized by an isolated thrombocytopenia with no underlying cause or precipitant. ITP is the commonest cause of thrombocytopenia in early pregnancy.
      • Thrombotic microangiopathies — these are defined by thrombocytopenia, microangiopathic haemolytic anaemia, and thrombosis.
      • Immune thrombocytopenia may be associated with various autoimmune disorders.
      • Infection (typically viral) may also cause a transient thrombocytopenia.
      • See the CKS topic on Platelets - abnormal counts and cancer for more information.
    • Henoch-Schlonlein purpura (HSP) [Anderson, 2010] 
      • This is a systemic vasculitis that can affect the skin, joints, bowels, and kidneys, and may follow an upper respiratory tract infection, usually in children.
      • It typically causes reddish-purple purpura on the backs of the legs, buttocks, trunk, and back, and may be associated with joint pains, swelling, and gastrointestinal symptoms.
      • Most cases spontaneously resolve within a few weeks.
    • Aplastic anaemia [Carpenter, 2022]
      • This is a bone marrow disorder that commonly presents with fatigue, recurrent infections, and mucosal bleeding due to anaemia, leucopenia, and thrombocytopenia.
    • Malignancy [Harrison, 2017] [Carpenter, 2022] [Dodderer, 2022] [Hughes, 2024] [NICE, 2026] 
      • Haematological malignancy with bone marrow infiltration causes reduced platelet production. Acute leukaemia, for example, may present with fatigue, weight loss, night sweats, mucocutaneous bleeding, bruising, and hepatosplenomegaly. It tends to cause pancytopenia and abnormal lymphoblasts or myeloblasts may be seen on the blood film. Other malignant causes include lymphoma and myeloma. See the CKS topics on Haematological cancers - recognition and referral and Multiple myeloma for more information.
      • Neuroblastoma in a child may present with periorbital bruising due to direct solid tumour involvement of the bone or a paraneoplastic process. In addition, there may be a palpable abdominal mass on examination.
    • End-stage chronic kidney disease [Harrison, 2017]
      • This may cause abnormalities of platelet aggregation and prolongation of bleeding time.
    • Liver disease [Harrison, 2017]
      • This may cause abnormalities of platelet function and number, the quality of clotting factors and proteins, and the quality of the skin and connective tissues.

Coagulation disorders

  • Coagulation disorders are caused by a reduction or inhibition of circulating clotting factors, and may be inherited or acquired. Be aware that a negative family history does not exclude a genetically inherited disorder [Biss, 2022] [Carpenter, 2022].
    • Haemophilia A (factor VIII deficiency) and haemophilia B (factor IX deficiency) [Carpenter, 2022] [Horn, 2025] 
      • These conditions have an X-linked recessive inheritance pattern. Factor VIII deficiency affects about 1 in 5000 live male births, and factor IX deficiency affects about 1 in 20,000 live male births. The most severe forms occur almost exclusively in males.
      • About one-third of cases have no known family history of haemophilia, and may represent new germ-line mutations, or an unknown family history of haemophilia. Rarely, phenotypic female carriers can be affected, for example, if there is consanguinity or Turner syndrome.
      • Clinical features depend on the level of clotting activity, and include intracranial haemorrhage, spontaneous haemarthrosis (affecting knees, ankles, and elbows, for example), and muscle haematomas in severe haemophilia.
    • Factor XIII and other factor deficiencies [Harrison, 2017] [Carpenter, 2022]
      • May be secondary to impaired synthesis of clotting factors due to liver disease or may be caused by drugs such as alcohol.
    • Vitamin K deficiency [Anderson, 2010] [Harrison, 2017] [Carpenter, 2022] [Hughes, 2024] 
      • This can result in functional deficiencies of factors II, VII, IX, and X, and proteins C and S, and can cause bleeding in a newborn infant in the first days of life if they have not received prophylactic vitamin K at birth. Classic-onset vitamin K deficiency bleeding occurs between the first week and the first month of life. Late vitamin K deficiency bleeding is more common in exclusively breastfed babies, as human milk contains less vitamin K than cow's milk.
      • Symptoms can vary from bruising or petechiae, large intramuscular haemorrage, to severe and life-threatening intracranial haemorrhage.
      • Vitamin K deficiency can also occur due to malnutrition, excess alcohol intake, or malabsorption due to coeliac disease, chronic pancreatitis, or inflammatory bowel disease, for example.
    • von Willebrand disease (vWD) [Carpenter, 2022] [Horn, 2025]
      • This is the most common inherited bleeding disorder. Low von Willebrand factor levels occur in 1% of the general population, but many people are asymptomatic, and the true estimated prevalence is 23–110 per 1,000,000 people.
      • A clear family history is not always evident, as there may be incomplete penetrance and variable expression among family members, and new mutations may occur.
      • It typically presents with mild to moderate mucocutaneous bleeding, such as nosebleeds, heavy menstrual bleeding, or prolonged bleeding after surgery or dental procedures.
    • Amyloidosis [Carpenter, 2022]
      • Abnormal bleeding is sometimes seen in people with amyloidosis. Underlying mechanisms are thought to include prolonged prothrombin time, elevated plasmin-α2-antiplasmin complex, and factor X deficiency.

Drugs

Drugs that may cause or worsen easy bruising include the following. This list is not exhaustive.

Diagnosis of bruising

How should I assess a person with bruising?

When assessing a person with reported easy or abnormal bruising:

  • Ask if the bruising is spontaneous or if there is any history of trauma.
    • If there is a history of trauma, assess whether the severity of bruising is proportional to the level of reported trauma, and whether there are any red flags for non-accidental injury. See the section on Red flags for non-accidental injury for more information.
  • Ask about symptoms which suggest an underlying platelet or coagulation disorder, such as:
    • Episodes of mucocutaneous bleeding including type, location, duration, frequency, and treatment needed, such as nosebleeds, gum bleeding, prolonged bleeding from minor wounds, gastrointestinal tract bleeding, haematuria, heavy menstrual bleeding, or severe or unexplained postpartum haemorrhage.
    • Previous excessive bruising, or excessive or prolonged bleeding which:
      • Occurs soon after trauma (particularly if it is associated with a petechial rash or mucocutaneous bleeding), suggesting a platelet disorder.
      • Is delayed, such as haemorrhage occurring 24 hours after trauma including dental extraction or surgery (particularly if it is associated with bruises, haemarthrosis, or muscle haematomas), suggesting a coagulation disorder such as haemophilia.
      • Is new-onset, following previously normal responses to trauma, suggesting an acquired bleeding disorder.
  • Assess for clinical features of underlying medical causes.
    • Tiredness, weight loss, fever, and/or night sweats may suggest an underlying malignancy.
    • Joint pain, swelling, or reduced range of movement may indicate haemarthrosis due to haemophilia.
    • Hypothyroidism may affect the skin and subcutaneous tissues. See the CKS topic on Hypothyroidism for more information.
    • Nutritional deficiency due to restricted or unusual diets or malnutrition can lead to coagulopathy, vascular fragility, and abnormal bruising. See the CKS topic on Adult malnutrition for more information.
    • A history of childhood chemotherapy or radiotherapy may increase the risk of a bone marrow disorder (such as myelodysplasia or leukaemia). See the CKS topics on Haematological cancers - recognition and referral and Platelets - abnormal counts and cancer for more information.
  • Ask about alcohol use, prescribed or over-the-counter drugs including risk of accidental ingestion.
  • Ask about a family history of:
  • Assess the bruising in the context of the person's age, mobility, developmental status, and any explanation for injury (if given). In children, ask if:
    • The child is independently mobile — bruising is uncommon in infants who are not yet mobile. See the section on Red flags suggesting non-accidental injury for more information.
    • The child may have accidentally ingested a drug (such as warfarin).
    • There is any history at birth of conditions suggesting an undiagnosed bleeding disorder, such as:
      • Cephalohaematoma after instrumental delivery.
      • Prolonged bleeding from the umbilical stump or delayed stump separation by up to 4 weeks, suggesting factor XIII deficiency, or sometimes haemophilia.
      • Haematoma after routine intramuscular vitamin K given at birth.
      • Bleeding from the newborn heel prick test or immunisation sites, suggesting factor XIII deficiency, or sometimes haemophilia.
  • If no bruises are currently present, ask the person to return for review when they reappear and to take photographs, if possible and clinically appropriate.
  • Assess the location and pattern of any bruising and take photographs, if possible and clinically appropriate.
    • Distribution, number, site, shape, and measured size of any bruises.
    • Dependent areas — suggests thrombocytopenia or stasis factors. See the CKS topic on Platelets - abnormal counts and cancer for more information. 
    • Atypical areas, such as on the trunk — suggests an underlying bleeding disorder or non-accidental injury. See the section on Red flags suggesting non-accidental injury for more information.
    • Patterned bruising, for example, the outline of a hand or implement (such as a belt). See the section on Red flags suggesting non-accidental injury for more information.
    • Only on the arms or legs — suggests trauma or changes in the skin or subcutaneous tissue.
    • Periorbital — may suggest trauma, neuroblastoma in a child, or amyloidosis (rare).
    • Dorsum of the hands, extensor surfaces of the forearms and shins — suggests senile purpura.
    • Note: the age of a bruise cannot be estimated accurately by a visual assessment of its colour.
  • Examine the skin, hair, and nails for:
    • Age-related changes.
    • Evidence of delayed healing, such as multiple scars or unhealed wounds — suggests corticosteroid use, hypothyroidism, ageing, self-inflicted injury, a collagen defect, or factor XIII deficiency.
    • Skin hyperextensibility and atrophic scars — may suggest Ehlers-Danlos syndrome.
    • Pallor — suggests anaemia, which may be associated with bleeding and/or malignancy. See the CKS topic on Anaemia - iron deficiency for more information.
    • Jaundice — suggests liver disease or haemolysis. See the CKS topics on Jaundice in the newborn and  Jaundice in adults for more information.
    • Petechiae (tiny, non-blanching, pinpoint red or purple macules less than 2 mm in diameter) — may be seen at object pressure points such as clothing clasps or buckles indicating a possible platelet disorder, or if in the distribution of the superior vena cava may follow coughing, vomiting, or strangulation.
    • Purpura (typically purple lesions 2–10 mm in diameter) — may suggest an underlying systemic vasculitis such as Henoch-Schonlein purpura or a platelet disorder.
    • Brittle hair and nails — suggests nutritional deficiency, ageing, hypothyroidism, or rarely  hereditary haemorrhagic telangiectasia.
  • Examine the joints for:
    • Hyperextensibility or elasticity — may suggest Ehlers-Danlos syndrome.
    • Swelling and tenderness — may indicate haemarthrosis due to haemophilia.
    • Tenderness — may be seen in acute leukaemia or neuroblastoma.
  • Examine the abdomen for:
    • Splenomegaly — suggests malignancy or thrombocytopenia.
    • Hepatomegaly — suggests malignancy or liver disease.
    • Ascites, distended veins, and/or spider telangiectasia — suggests chronic liver disease. See the CKS topic on Jaundice in adults for more information.
  • Examine the head and neck:
    • The oropharynx — for signs of bleeding, trauma, or healing injury to the frenulae (may suggest non-accidental injury); gum hypertrophy may occur in monocytic leukaemia or vitamin C deficiency; purpura on the buccal mucosa or tongue may be a sign of severe thrombocytopenia.
    • The eyes — check for retinal haemorrhages (may suggest other non-accidental injury).
  • Examine for lymphadenopathy:

Red flags for non-accidental injury

Bruising is the most common injury sustained by children who have been subject to physical abuse [RCPCH, 2020]. See the CKS topic on Child maltreatment - recognition and management for detailed information on when to suspect or consider physical abuse and other forms of child maltreatment.

  • Suspect non-accidental injury and physical abuse in infants, children, the elderly, people with a learning disability, and other vulnerable people if there are the following features:
    • Bruises are on a child who is not yet independently mobile (by crawling, cruising, bottom shuffling, or walking) [Anderson, 2010] [RCPCH, 2020] [Biss, 2022] [Hughes, 2024] [NICE, 2025].
      • Bruising appropriate to learning to walk is common from around 1 year of age when most children have started 'cruising'. It is typically distributed on the bony prominences of the legs, such as the anterior tibia and knee, and the front of the face in a T-shaped distribution involving the forehead, nose, upper lip, and chin.
    • Bruises have indicative features [Anderson, 2010] [RCPCH, 2020] [Biss, 2022] [Hughes, 2024].
      • Disproportionate to the explanation of injury sustained.
      • Unusually large.
      • Present in multiple sites or in clusters.
      • Of a similar shape and size.
      • Patterned in the shape of a hand, ligature, stick, teeth mark, grip, or implement (such as a belt).
      • Associated with petechiae or purpura.
    • Bruises are found in indicative places [Anderson, 2010] [RCPCH, 2020] [Anderst, 2022] [Biss, 2022] [Hughes, 2024] [NICE, 2025].
      • Sites that are not typical for the age of a child.
      • Any non-bony part of the body or face (including the eyes, ears, cheeks, back, abdomen, buttocks, arms, and genitalia).
      • On the neck consistent with strangulation.
      • On the ankles and wrists consistent with use of a ligature.
    • The explanation for the bruising is implausible, inadequate, or inconsistent [NICE, 2025]:
      • With a person's presentation, normal activities, existing medical condition, age or developmental stage, or account, compared with that given by parents or carers.
      • Between parents or carers.
      • Between accounts over time.
    • There is a delay in presentation [NICE, 2025].

Basis for recommendation

The recommendations on assessment are largely based on the National Institute for Health and Care Excellence (NICE) guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2025], the British Society for Haematology (BSH) good practice paper Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment [Biss, 2022], the Royal College of Paediatrics and Child Health (RCPCH) publication Child protection evidence. Systematic review on bruising [RCPCH, 2020], an American Academy of Pediatricians (AAP) technical report Evaluating for suspected child abuse: conditions that predispose to bleeding [Carpenter, 2022] and an AAP clinical report Evaluation for bleeding disorders in suspected child abuse [Anderst, 2022], and expert opinion in review articles [Anderson, 2010; Harrison, 2017; Hughes, 2024; Horn, 2025].

Clinical features on history-taking

  • The recommendation to assess for red flags suggesting non-accidental injury if there is a history of trauma is based on the RCPCH publication [RCPCH, 2020] and expert opinion in review articles [Harrison, 2017; Hughes, 2024].
  • The information about symptoms suggesting an underlying platelet or coagulation disorder is based on the BSH good practice paper [Biss, 2022], the AAP technical report [Carpenter, 2022], and expert opinion in review articles [Anderson, 2010; Hughes, 2024]. 
    • The BSH good practice paper highlights that a bleeding history is important to identify people who may have an inherited bleeding disorder. In addition, the presence of multiple bleeding symptoms and/or severe bleeding symptoms increases the risk of an underlying bleeding disorder [Biss, 2022].
    • A negative history of bleeding in a child does not exclude a diagnosis of a bleeding disorder. A history of mucocutaneous bleeding may suggest a platelet disorder or severe von Willebrand disease [Anderson, 2010].
    • Expert opinion in a review article notes that age at symptom onset is significant, as severe inherited disorders typically present in infancy or early childhood [Hughes, 2024].
    • Expert opinion in another review article notes that in bleeding disorders, minor trauma can cause disproportionate severe bleeding [Horn, 2025].
  • The recommendation to assess for clinical features of underlying medical causes is based on the AAP technical report [Carpenter, 2022] and expert opinion in review articles [Anderson, 2010; Harrison, 2017; Hughes, 2024].
    • Expert opinion in a review article notes that malnourishment or a limited or restricted diet can result in vitamin K deficiency [Anderson, 2010].
  • The recommendation to assess alcohol, drug, and medication use is based on the BSH good practice paper [Biss, 2022], the AAP technical report [Carpenter, 2022], the AAP clinical report [Anderst, 2022], and expert opinion in review articles [Anderson, 2010; Harrison, 2017; Hughes, 2024].
  • The recommendation to assess the person's family history is based on the BSH good practice paper [Biss, 2022], the AAP technical report [Carpenter, 2022], and expert opinion in review articles [Anderson, 2010; Harrison, 2017; Hughes, 2024]. 
    • The BSH good practice paper notes that a positive family history is of limited value, as only 50% of new diagnoses of severe haemophilia A in boys have a positive family history [Biss, 2022].
    • Similarly, the AAP technical report notes that personal medical history and family history do not predict the presence of bleeding disorders in studies [Carpenter, 2022].
    • Expert opinion in a review article notes that when taking a family history, the timing and severity of bleeding or bruising symptoms, and sex of the family member may help to identify hereditary patterns. Reviewing several generations and the medical history of extended family members can indicate X-linked recessive haemophilia, connective tissue disease, and von Willebrand disease due to incomplete penetrance and variable expression [Hughes, 2024].

Clinical features on examination

  • The recommendation to assess the bruising in the context of the person's age, mobility, developmental status, and any explanation for injury is based on the BSH good practice paper [Biss, 2022], the RCPCH publication [RCPCH, 2020], the AAP technical report [Carpenter, 2022], the AAP clinical report [Anderst, 2022], and expert opinion in a review article [Anderson, 2010].
    • The BSH good practice paper recommends assessing the developmental stage of a child, as the frequency and nature of normal bruising, and the likelihood of sustaining an injury, varies with the child's degree of mobility and development. It states that 'assessment of a child aims to differentiate injuries suggestive of physical maltreatment from findings that may be normal for the developmental stage of the child and from bruising/bleeding associated with an underlying bleeding disorder'. It documents specific anatomical sites of bruising that are more likely to be associated with physical abuse [Biss, 2022].
    • Similarly, the RCPCH publication states that 'a bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage, explanation given, full clinical examination and relevant investigations'. It highlights 'the importance of recognising abnormal characteristics of bruising in children, enabling detection as early as possible and potentially preventing escalation of abuse with avoidance of serious abusive injury or death'. It notes that accidental bruising in pre-mobile infants is rare and seen in up to 1.3% of infants, whereas up to 79% of children who are walking exhibit some bruising [RCPCH, 2020].
    • The AAP technical report also states that 'the age and developmental capabilities of the child, history of trauma, and the location and pattern of bruising often provide significant evidence in determining the presence of abusive injury' [Carpenter, 2022].
  • The recommendation to advise to keep a photographic record of any bruising is based on expert opinion in a review article, which recommends to compare patient-provided photographs with physical examination findings, if possible, and notes that photographic evidence of bruising may help to monitor progression or resolution [Hughes, 2024]. This approach is supported by expert opinion in another review article [Harrison, 2017].
  • The recommendation to assess the location and pattern of any bruising is based on the BSH good practice paper [Biss, 2022], the RCPCH publication [RCPCH, 2020], the AAP technical report [Carpenter, 2022], and expert opinion in review articles [Anderson, 2010; Harrison, 2017; Hughes, 2024].
    • Expert opinion in a review article notes that 'bruising patterns that may indicate child abuse are distinct from those occurring from developmentally consistent accidental trauma' [Hughes, 2024].
    • The information that the age of a bruise cannot be estimated accurately by a visual assessment of its colour is based on the RCPCH publication.
  • The recommendations to perform a general examination to assess for specific clinical features which may suggest an underlying cause for bruising are based on the BSH good practice paper [Biss, 2022], the RCPCH publication [RCPCH, 2020], the AAP technical report [Carpenter, 2022], and expert opinion in review articles [Anderson, 2010; Harrison, 2017; Hughes, 2024]. They are also pragmatic, based on what CKS considers to be good clinical practice.
    • Expert opinion in a review article notes that signs of anaemia on examination may indicate the severity or chronicity of bleeding [Hughes, 2024].
    • Widespread petechiae, bruising, and mucosal bleeding may indicate thrombocytopenia [Biss, 2022].
    • The presence of petechiae with bruising occurs more commonly in abuse than accidental injuries in children [RCPCH, 2020].

How should I investigate a person with bruising?

If a person presents with easy bruising, be aware that blood results such as full blood count and coagulation screen can be normal in people with mild coagulation and platelet function disorders.

  • If an adult has unexplained bruising or bleeding arrange blood tests, the urgency depending on clinical judgement.
    • A full blood count including platelet count and blood film — arrange this on a 'very urgent' basis within 48 hours if a diagnosis of leukaemia is suspected. See the CKS topic on Haematological cancers - recognition and referral for more information.
    • Coagulation screen (including prothrombin time, activated partial thromboplastin time, and fibrinogen level), and international normalized ratio (INR) if the person is taking warfarin.
    • Liver, renal, and thyroid function tests, depending on clinical judgement.
  • If a child or young person has unexplained bruising or bleeding arrange blood tests, depending on local availability and clinical judgement.
    • A full blood count including platelet count and blood film — arrange this on a 'very urgent' basis within 48 hours if a diagnosis of leukaemia is suspected. See the CKS topic on Haematological cancers - recognition and referral for more information.
    • Coagulation screen (including prothrombin time, activated partial thromboplastin time, and fibrinogen level).

Basis for recommendation

The recommendations on investigation of easy bruising are largely based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2026], the British Society for Haematology (BSH) good practice paper Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment [Biss, 2022], an American Academy of Pediatricians (AAP) technical report Evaluating for suspected child abuse: conditions that predispose to bleeding [Carpenter, 2022] and an AAP clinical report Evaluation for bleeding disorders in suspected child abuse [Anderst, 2022], and expert opinion in review articles [Anderson, 2010; Harrison, 2017; Hughes, 2024].

Arranging blood tests in adults

  • The information that blood test results such as full blood count (FBC) and coagulation screen can be normal in people with mild coagulation and platelet function disorders is extrapolated from the BSH good practice paper [Biss, 2022], the AAP technical report [Carpenter, 2022], and expert opinion in a review article [Hughes, 2024].
  • Expert opinion in a review article recommends checking a FBC, as a low haemoglobin may indicate that bruising is longstanding or that there is bleeding elsewhere. An isolated low platelet count suggests thrombocytopenia as a cause of bruising, and an abnormal white cell count in combination with a low platelet count suggests a bone marrow disorder. Abnormal platelet morphology on blood film may suggest an inherited platelet disorder [Harrison, 2017].
  • The recommendation to arrange a very urgent FBC if a diagnosis of leukaemia is suspected is based on the NICE guideline on suspected cancer [NICE, 2026].
  • The BSH good practice paper notes that no single panel of blood tests can definitively rule out a bleeding disorder diagnosis. It states that initial blood tests are primarily used to identify or exclude an acquired condition. It notes that many inherited bleeding disorders will not be ruled out by first-line investigations, but coagulation screening may identify features such as an isolated prolonged activated partial thromboplastin time (APTT) in people with severe haemophilia [Biss, 2022].
  • Expert opinion in a review article recommends checking a FBC to assess platelet count and size, blood film to assess platelet and leucocyte morphology, and coagulation screen including prothrombin time (PT) to assess extrinsic and common coagulation pathways, APTT to assess the intrinsic coagulation pathway, von Willebrand factor assay, and assays of factors VIII and IX to exclude mild forms of haemophilia, even if the APTT is normal [Anderson, 2010]. CKS notes that specific coagulation factor assays may be arranged following specialist haematology referral.
  • The AAP clinical report states that most clotting factor deficiencies can be detected by the PT and APTT, except for von Willebrand disease, factor XIII deficiency, and mild deficiencies in factor VIII or IX [Anderst, 2022].
  • The AAP technical report lists factors that may prolong APTT and/or PT which may need to be taken into account, including some medications, underlying medical conditions unrelated to bleeding disorders, the temperature of the blood sample, and duration between venepuncture and laboratory testing [Carpenter, 2022].
  • Expert opinion in a review article recommends testing liver function if the PT and APTT are prolonged [Hughes, 2024]. The recommendation to check renal and thyroid function are extrapolated from expert opinion in another review article [Harrison, 2017]. In addition, impaired renal function in people taking anticoagulant drugs that require renal clearance, such as direct-acting oral anticoagulants (DOACs), can cause excessive anticoagulation and subsequent bruising or bleeding [BNF, 2025].

Arranging blood tests in children

  • The recommendation to arrange blood tests in children is extrapolated from the BSH good practice paper, which states that if child maltreatment is suspected, blood tests can help to 'identify or exclude the presence of an inherited or acquired bleeding disorder that may have influenced the propensity to bruising/bleeding' if a child presents with bruising or bleeding [Biss, 2022].
  • The AAP clinical report states that 'bleeding disorders that can produce patterns of bruising or bleeding that may mimic abuse include coagulation factor deficiencies/abnormalities, fibrinolytic defects, defects of fibrinogen, and platelet disorders' [Anderst, 2022].
  • The recommendation to arrange a very urgent FBC if a diagnosis of leukaemia is suspected is based on the NICE guideline on suspected cancer [NICE, 2026].
  • The recommendation to arrange a coagulation screen is extrapolated from expert opinion in a review article [Anderson, 2010].

What else might it be?

  • Skin conditions that may present similarly to bruising include:
    • Linear eruptions
      • Allergic contact dermatitis. See the CKS topic on Dermatitis - contact for more information.
      • Phytophotodermatitis — an inflammatory and pigmentary reaction of the skin to ultraviolet radiation following contact with phototoxic substances from certain plants, such as giant hogweed.
      • Striae (stretch marks).
    • Non-linear eruptions
      • Acute haemorrhagic oedema of infancy — may present with multiple purpuric lesions which may mimic bruising.
      • Congenital dermal melanocytosis (formally known as 'Mongolian blue spots') — macular blue-grey non-tender macules present at birth, often on the lumbosacral and gluteal areas in healthy infants with darker skin tones, but may be present on other body sites.
      • Haemangiomas and arteriovenous malformations — benign congenital cutaneous tumours.
      • Urticaria pigmentosa — numerous reddish-brown macules or papules which develop localized urticaria and erythema within a few minutes of gentle rubbing or scratching. They are usually distributed symmetrically on the trunk and limbs, but can present anywhere on the body. See the CKS topic on Urticaria for more information.
      • Dermatitis artefacta — self-inflicted skin lesions.
      • Congenital melanocytic naevi.
    • Other
      • Skin staining from dye or ink.
      • Cultural practices such as 'coining' (where coin rubbing causes dermabrasion) and 'cupping' (where cups create local suction on the skin to promote healing).
      • Subgaleal haematoma on the scalp — may be a result of hair braiding.

Basis for recommendation

The information on the differential diagnosis of bruising is largely based on the British Society for Haematology (BSH) good practice paper Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment [Biss, 2022], the Royal College of Paediatrics and Child Health (RCPCH) publication Child protection evidence. Systematic review on bruising [RCPCH, 2020], and expert opinion in review articles [Ward et al, 2013; Patel, 2015]. It is also pragmatic, based on what CKS considers to be good clinical practice.

Management

Scenario: Management of bruising

From age 1 month onwards.

When should I admit or refer a person with abnormal bruising?

  • If a person has significant or progressive active bleeding not responding to first aid measures where appropriate, advise to attend an emergency department.
    • Be aware that people with a known heritable bleeding disorder or haemophilia may carry a 'bleeding disorder alert card' which specifies the person's diagnosis, baseline coagulation factor levels, usual product for treatment, and contact details for their haemophilia specialist.
    • Be aware that people with severe or moderate bleeding disorders may have self-treated at home with a coagulation factor concentrate before attending an emergency setting or may be on prophylaxis.
  • If non-accidental injury is suspected and there are safeguarding concerns, refer immediately to the most appropriate agency such as local child or adult social care or the police.
    • Follow local referral processes for child and adult safeguarding, share information appropriately, and participate in multi-agency and multi-disciplinary working. See the CKS topic on Child maltreatment - recognition and management for more information.
  • If non-accidental injury is not suspected:
    • Refer children and young people for immediate specialist assessment for suspected leukaemia if there is:
    • Refer children with periorbital bruising urgently (for an appointment within 48 hours) for specialist assessment for suspected neuroblastoma if there is:
      • A palpable abdominal mass, or
      • An unexplained enlarged abdominal organ.
    • For all other children, liaise with a paediatrician or paediatric haematologist to arrange assessment and follow-up as clinically indicated.
    • Refer adults for immediate specialist assessment for leukaemia if there is:
    • Refer all other adults to a haematologist for further investigations, the urgency depending on clinical judgement, if there is:
      • A low platelet count. See the CKS topic on Platelets - abnormal counts and cancer for more information.
      • An abnormal coagulation screen or uncertainty in the interpretation of blood results.
      • Normal blood results in primary care but a bleeding disorder is still suspected, for example, if there is a significant bleeding history or positive family history.

Basis for recommendation

The recommendations on admission and referral are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2025] and Suspected cancer: recognition and referral [NICE, 2026], the British Society for Haematology (BSH) good practice paper Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment [Biss, 2022], the AAP clinical report Evaluation for bleeding disorders in suspected child abuse [Anderst, 2022], the Royal College of General Practitioners (RCGP) publication Summary of safeguarding knowledge and capabilities [RCGP, 2024], and expert opinion in review articles [Anderson, 2010; Harrison, 2017; Dodderer, 2022; Hughes, 2024; Horn, 2025].

Arranging emergency hospital assessment
  • These recommendations are extrapolated from expert opinion in review articles [Anderson, 2010; Horn, 2025]. 
    • Expert opinion in a review article highlights the importance of prompt triage and assessment of patients with haemophilia and heritable bleeding disorders needing emergency care, as delays may lead to increased risk of morbidity and mortality. It also outlines that people with a known heritable bleeding disorder or haemophilia may carry a 'bleeding disorder alert card', and that some people may have self-treated before attending an emergency setting [Horn, 2025].
    • Expert opinion in a review article notes that emergency management of acute active bleeding may involve hospital administration of recombinant factor products, for example factor VIII products for an underlying haemophilia A [Anderson, 2010].
Management of suspected non-accidental injury
  • These recommendations are based on the RCGP publication, which summarizes key areas of safeguarding knowledge and capabilities in general practice [RCGP, 2024].
Arranging specialist referral in children
  • The recommendation if there is suspected leukaemia is based on the NICE guideline on suspected cancer [NICE, 2026].
  • The recommendation if there is suspected neuroblastoma is based on the NICE guideline on suspected cancer [NICE, 2026] and expert opinion in a case report on neuroblastoma [Dodderer, 2022].
  • The recommendation regarding general paediatric or paediatric haematology referral is extrapolated from the BSH good practice paper [Biss, 2022], the AAP clinical report [Anderst, 2022], and expert opinion in a review article [Anderson, 2010].
    • Expert opinion in a review article recommends early involvement of a paediatric haematologist or haematologist with an interest in haemostasis to ensure optimal investigation of a child presenting with easy bruising or bleeding. It notes that specialist paediatric haematology input may be needed in the investigation of a child with easy bruising, to help with interpretation of initial laboratory results and to arrange specialist additional tests to assess for other platelet function defects and factor XIII deficiency, for example. In addition, it notes that paediatric blood samples can be difficult to take, should not be traumatic, and should be analysed appropriately and without delay. Non-traumatic venepuncture is particularly important in a child with a bleeding disorder, in order to prevent further bruising or haematoma formation, and to prevent activation of coagulation in the blood samples [Anderson, 2010].
    • The AAP clinical report states that abnormal laboratory test results require further evaluation for the possibility of false positive results and/or the need for further specialist testing. It recommends specialist paediatric haematology input if 'expanded testing' is needed, if initial testing suggests the presence of a bleeding disorder, if testing is needed to rule out a specific bleeding disorder, or if testing for very rare conditions is felt necessary [Anderst, 2022].
    • The BSH good practice paper states that if an inherited bleeding disorder is suspected, specialist haematology second-line coagulation testing may be needed including clotting factor assays, von Willebrand disease testing, and platelet function tests. Of interest, fibrinogen, factor VIII and von Willebrand factor are acute phase proteins which may be raised in response to infection, inflammation, trauma, surgery, or venepuncture, and therefore need specialist interpretation and care with timing of venepuncture samples [Biss, 2022].
Arranging specialist referral in adults
  • The recommendation if there is suspected leukaemia is based on the NICE guideline on suspected cancer [NICE, 2026].
  • The recommendation if there is thrombocytopenia on blood testing is extrapolated from the AAP clinical report [Anderst, 2022] and expert opinion in review articles [Harrison, 2017; Hughes, 2024].
  • The recommendation if there is an abnormal coagulation screen or uncertainty in interpretation of results is extrapolated from the AAP clinical report [Anderst, 2022] and expert opinion in review articles [Harrison, 2017; Hughes, 2024].
    • Expert opinion in a review article outlines when specialist haematology referral should be arranged, and states that specialist tests include screening for von Willebrand disease, coagulation factor assays, platelet function tests, and tests to exclude collagen vascular disorders [Harrison, 2017].
  • The recommendation if there are normal blood results but a bleeding disorder is still suspected is based on expert opinion in review articles [Harrison, 2017; Hughes, 2024].
    • Expert opinion in a review article states that haematology referral is needed if initial tests suggest a bleeding disorder or a bleeding disorder is still suspected despite initial normal test results. Specialist haematology assessment may allow advanced testing and diagnosis of an underlying condition [Hughes, 2024].

How should I manage bruising in primary care?

If hospital admission or specialist referral is not needed following initial assessment:

  • If a person has simple bruising and no suspected underlying bleeding disorder:
    • Offer reassurance and advise to attend for review if bruising persists, worsens, or there are new associated features.
    • Advise on the use of simple analgesia such as paracetamol, if needed. See the CKS topic on Analgesia - mild-to-moderate pain for more information.
  • If a person is taking a potentially causative drug:
    • If taking warfarin with an abnormal coagulation screen (a prolonged prothrombin time or increased international normalized ratio [INR]) and the person is monitored and managed in primary care:
      • Alter the warfarin dosage and arrange monitoring according to local protocols, or liaise with the local warfarin clinic or a haematologist, depending on clinical judgement. See the CKS topic on Anticoagulation - oral for more information.
    • If taking a drug which may cause thrombocytopenia, reduce and stop the drug if clinically appropriate, and monitor the person. See the CKS topic on Platelets - abnormal counts and cancer for more information.
      • If bruising or bleeding symptoms do not improve after stopping the drug, consider seeking specialist advice or arranging referral for further assessment, depending on clinical judgement. See the section on Admission and referral for more information.

Basis for recommendation

The recommendations on management in primary care are based on expert opinion in review articles [Harrison, 2017; Hughes, 2024]. They are also pragmatic, based on what CKS considers to be good clinical practice.

Management of simple bruising
  • The recommendations about offering reassurance and giving safety netting advice are based on expert opinion in a review article [Harrison, 2017]. They are also pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation to prescribe simple analgesia if needed is pragmatic, based on what CKS considers to be good clinical practice.

Management if taking a potentially causative drug

  • The recommendation if a person is taking warfarin is pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendations if a person is taking a drug which may potentially cause thrombocytopenia are based on expert opinion in review articles, as further assessment is needed to exclude a bleeding disorder [Harrison, 2017; Hughes, 2024]. They are also pragmatic, based on what CKS considers to be good clinical practice.

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guidelines Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2025] and Suspected cancer: recognition and referral [NICE, 2026], together with the British Society for Haematology (BSH) good practice paper Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment [Biss, 2022], two American Academy of Pediatricians (AAP) reports [Anderst, 2022; Carpenter, 2022], and expert opinion in review articles. The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on the primary care management of bruising and purpura.

Search dates

February 2021 - February 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Contusions/
  • contusion$.tw., or bruis$.tw., or petechia$.tw.
  • exp Ecchymosis/
  • ecchymos$.tw., or purpura.tw.
  • haematoma or hematoma.ti,ab.
  • linear or non linear.ti,ab.
  • exp Purpura/

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
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  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
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  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
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    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
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Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

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  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
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Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

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Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Anderson, J.A.M. and Thomas, A.E. (2010) Investigating easy bruising in a child. BMJ 341, c4565. [Abstract]
  • Anderst, J., Carpenter, S.L., Abshire, T.C. and Killough, E. (2022) Evaluation for bleeding disorders in suspected child abuse. Pediatrics 150(4). [Abstract]
  • Biss, T., Sibson, K., Baker, P., et al. (2022) Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment: a British Society for Haematology good practice paper. British Journal of Haematology 199(1), 45-53. [Abstract]
  • BNF (2025) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • Carpenter, S.L., Abshire, T.C., Killough, E., et al. (2022) Evaluating for suspected child abuse: conditions that predispose to bleeding. Pediatrics 150(4). [Abstract]
  • Dodderer, J.K., Aziz-Bose, R. and Nagler, J. (2022) Infant with unilateral periorbital ecchymosis. Annals of Emergency Medicine 79(2), 116-147. [Abstract]
  • Harrison, L.B., Nash, M.J., Fitzmaurice, D. and Thachil, J. (2017) Investigating easy bruising in an adult. BMJ 356(j251). [Abstract]
  • Home Office (2023) Domestic abuse: statutory guidance. Home Office. http://www.gov.uk [Free Full-text]
  • Horn, E.H., Forsyth, K., Gooding, R., et al. (2025) Management of haemophilia and heritable bleeding disorders in the ED. Emergency Medicine Journal 43(1), 49-54. [Abstract]
  • Hughes, P.R., Lewis, M.N. and Adams, S.S. (2024) Bleeding and bruising. American Family Physician 110(5), 504-514. [Abstract]
  • NICE (2025) Child maltreatment: when to suspect maltreatment in under 18s. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • NICE (2026) Suspected cancer: recognition and referral. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • Patel, B. and Butterfield, R. (2015) Common skin and bleeding disorders that can potentially masquerade as child abuse. American Journal of Medical Genetics Part C 169(4), 328-336. [Abstract]
  • RCGP (2024) Summary of safeguarding knowledge and capabilities. Royal College of General Practitioners. https://www.rcgp.org.uk [Free Full-text]
  • RCPCH (2020) Child protection evidence: systematic review on bruising. Royal College of Paediatrics and Child Health. https://www.rcpch.ac.uk [Free Full-text]
  • Ward, M.G.K, Ornstein, A. and Niec, A. et al (2013) The medical assessment of bruising in suspected child maltreatment cases: a clinical perspective. Paediatrics and child health. 18(8), 433-442. [Abstract]
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