4 Min In Clinical
Follow this topic
Bookmark
Record learning outcomes
Key points: unexplained bruising
- This is a common problem, generally with benign aetiology
- Bleeding associated with bruising suggests a non-benign cause
- Fatigue and weight loss may suggest serious underlying disorders.
Problem representation
A 46-year-old woman presents with a long-standing history of unexplained bruising.
Hypothesis generation
A bruise (ecchymosis) is a pooling of blood beneath the skin resulting from capillary fragility leading to leakage of blood from surrounding vessels. Bruises typically appear as red/brown discolouration that does not blanch on pressure. The colour gradually fades to a brownish yellow and usually disappears within two to three weeks.
Trauma is the most common and obvious cause, but bruising can result from abnormalities affecting the blood vessels, the surrounding skin and subcutaneous structures, platelet number and function, or coagulation cascade dysfunction.
Many patients say they bruise easily, but only a minority will have an underlying blood disorder.
Likely diagnosis
- Actinic purpura (senile purpura)
- Alcohol use disorder
- Purpura simplex (easy bruising syndrome)
- Medicines.
Possible diagnosis
- Child abuse (not applicable in this case)
- Coagulation disorders
- Cushing’s or Ehlers-Danlos syndrome
- Henoch-Schönlein purpura (almost always seen in children, so not applicable in this case)
- Idiopathic thrombocytopenic purpura (almost always in children, so not applicable in this case)
- Liver disease
- Marfan’s syndrome
- Vitamin C deficiency (scurvy).
Critical diagnosis
- Aplastic anaemia
- Hereditary haemorrhagic telangiectasia
- Malignancy.
Continued information gathering
From the likely causes, two can be discounted straight away. This patient is too young to consider actinic purpura and does not take any regular medicines. Therefore, you need to establish if alcohol or purpura simplex are responsible. Asking directly about alcohol consumption may be perceived by the patient as being offensive or insensitive, so you could ask this question by establishing a wider social history.
You establish that she does drink and it appears she drinks more than the UK recommended 14 units per week but the description of her drinking patterns does not suggest an alcohol dependence. This seems to rule out alcohol consumption as a cause of the bruising.
Given the patient’s age, purpura simplex is now looking the most likely cause of her symptoms. She mentioned bruising to her arms and legs, which is also consistent with this condition.
Problem refinement
Based on your working differential diagnosis of purpura simplex, you could ask more about the bruising to establish if this occurs on other parts of her body. The patient tells you that the bruising is not just limited to her arms and legs as she has previously noticed bruising low down on her lower back. Again, this fits with purpura simplex.
At this point, it would be appropriate to review the patient’s symptoms to make sure that other possible causes are not responsible.
On presentation, she did not report any other symptoms. This needs to be explored as the possible causes are associated with other signs: menorrhagia is associated with Von Willebrand disease (coagulation disorder) and Ehlers-Danlos syndrome; weight gain with Cushing’s; bleeding easily with hereditary coagulation problems and liver disease; stretch marks with Marfan’s syndrome; and malaise with Vitamin C deficiency.
The patient tells you that she generally feels fine, her periods are normal and she hasn’t noticed any weight changes. The lack of any other symptoms supports your diagnosis and seems to rule out other possible causes.
Red flags
All critical diagnoses are associated with other symptoms – most notably fatigue and bleeding. The patient does not show any of these symptoms.
Management
- Self-care options
The patient could be told that sun exposure can make the problem worse, so a sunscreen should be used. She should not take aspirin as this is also a risk factor.
- Prescribing options
No treatment is required. However, it would be prudent for her GP to run blood tests to make sure that none of the possible causes are indeed responsible for her symptoms. Results will be normal in purpura simplex.
Safety netting
You tell the patient that you think her bruising is something called purpura simplex and there is no known reason why people get this problem, although it is quite common. She should have some blood tests to make sure.
If you are right, there are no medicines to treat this condition. However, limiting exposure to the sun, not taking aspirin and avoiding unnecessary body contact (e.g. certain sports) might help.
Causes: conditions to consider
Likely diagnoses
Actinic purpura (also known as senile purpura)
A common and benign condition that usually affects the elderly. It results from impaired collagen production and capillary fragility.
The condition is characterised by dark purple, irregularly shaped macules on photo-exposed areas, especially the back of the hands and the extensor surfaces of the forearm.
Lesions do not undergo the colour changes of a bruise and take up to three weeks to resolve. Physical examination will reveal thin, fragile, inelastic skin.
Alcohol use disorder
While alcohol itself does not lead to skin bruising, it can make a person bruise more easily. This is because regular alcohol consumption reduces platelet aggregation and prolongs bleeding time, as well as causing vasodilation.
Medication
Many medicines can cause bleeding or bruising. Antiplatelet and anticoagulation agents are most commonly implicated. These include:
- Antiplatelets: Aspirin, NSAIDs, clopidogrel
- Anticoagulants: Apixaban, dabigatran, enoxaparin, heparin, rivaroxaban, warfarin.
Other medicines to consider include corticosteroids (via collagen degradation), SSRIs (antiplatelet effect) and those that cause thrombocytopenia (e.g. antibiotics, carbamazepine, valproic acid, thiazide diuretics).
Purpura simplex (easy bruising syndrome)
Purpura simplex is common, especially in women in their 20s and 30s. Bruises develop on the thighs, buttocks and upper arms without known trauma. A history usually reveals no other abnormal bleeding and the condition is typically not associated with any other symptoms or systemic complications.
Possible diagnoses
Coagulation disorders
These include haemophilia, vitamin K deficiency and Von Willebrand disease.
People with haemophilia usually begin to notice their symptoms when they are old enough to run about and hurt themselves. Symptoms depend on the level of clotting activity and include spontaneous haemarthrosis (bleeding into a joint, leading to joint pain, stiffness and swelling), especially of the knees, ankles and elbows.
Vitamin K deficiency can cause bleeding in an infant in the first weeks of life, when it is known as haemorrhagic disease of the newborn. Symptoms of bruising or petechiae (red pinprick spots under the skin) are seen in the first few days of life. Vitamin K deficiency can also occur due to malabsorption caused by conditions such as coeliac or inflammatory bowel disease.
Von Willebrand disease may take years to diagnose as it tends to present with mild to moderate mucocutaneous bleeding, such as nosebleeds, gum bleeding and menorrhagia.
Cushing’s syndrome
This is a rare condition that is more common in women between 20 and 50 years of age. Patients with Cushing’s syndrome often display weight gain with central obesity, a red puffy, rounded face, muscle weakness and thinning of the skin that leads to easy bruising.
Ehlers-Danlos syndrome or connective tissue diseases
Ehlers-Danlos syndrome is a group of inherited disorders that affects collagen or connective tissue synthesis and structure. Clinically, it exhibits hyperextensible skin, skin fragility, easy bruising and joint laxity. It may also present with gingival bleeding, prolonged bleeding after surgical procedures and menorrhagia.
Henoch-Schönlein purpura
Most commonly affects children under 10 years. Typically, the rash starts as red spots which rapidly change to small, dark purple purpura within the first 24 hours. The most common sites involved are the lower legs, buttocks, elbows and knees. The rash is symmetrical. Joint (ankle and/or knee) and abdominal pain is common.
Liver disease
The liver normally produces clotting factors that help to stop bleeding. In liver disease, abnormalities of platelet function and number, and in the quality of clotting factors and proteins, can occur. This can result in increased bruising and bleeding, even from minor injuries.
Acute idiopathic thrombocytopenic purpura (ITP)
Acute ITP is usually seen in children. It results in the production of antibodies against platelets. Clinically, patients can easily bruise, have sudden onset of petechiae, nosebleeds and menorrhagia. They usually remain systemically well. Most children will completely recover, although approximately 10 per cent will develop chronic idiopathic thrombocytopenic purpura.
Marfan’s syndrome
Marfan’s syndrome is a connective tissue disorder that mainly affects the eyes, skeletal and cardiovascular systems. Skin features appear as striae or stretch marks that develop even without any significant weight change. They tend to appear at sites subjected to stress, such as the shoulders, hips, buttocks and lower back.
Vitamin C deficiency (scurvy)
Scurvy remains surprisingly common and is seen in children with very restricted diets, pregnant women, those affected by malabsorption, cancer patients, the elderly, and people on low incomes. Those affected may complain of general malaise and lethargy. Skin features include perifollicular haemorrhage (bleeding around hair follicles), bruising, bleeding gums, poor wound healing, and coiled hairs.
Critical diagnoses
Aplastic anaemia
Aplastic anaemia is a rare bone marrow disorder in which all types of blood cells are reduced (pancytopenia). The most common symptom is bruising, often without experiencing trauma. Sometimes, the low number of platelets shows as petechiae. Other symptoms can result from infections and anaemia (fatigue, pallor, dyspnoea, tachycardia).
Hereditary haemorrhagic telangiectasia
This is a rare genetic disorder that leads to small red-to-violet telangiectatic lesions on the face, lips, oral and nasal mucosa, and tips of the fingers and toes. Patients may experience recurrent, profuse nosebleeds.
Malignancy (with bone marrow involvement)
Often presents with fatigue, recurrent infections, anaemia, fever, and mucosal bleeding or bruising. The patient will be systemically unwell and experience weight loss.
1. Which ONE of the following is a common cause of easy bruising in elderly individuals?
a. Age-related thinning of the skin and blood vessels
b. Chronic kidney disease
c. Increased sun exposure
d. Liver cirrhosis
e. Vitamin C deficiency
2. Which ONE of the following hereditary conditions should be considered in a patient with easy bruising and hyperflexible joints?
a. Cystic fibrosis
b. Down’s syndrome
c. Ehlers-Danlos syndrome
d. Marfan’s syndrome
e. Wilson’s disease
3. In a child presenting with multiple bruises of varying stages of healing, which ONE of the following is the most likely diagnosis?
a. Aplastic anaemia
b. Henoch-Schönlein purpura
c. Hereditary haemorrhagic telangiectasia
d. Non-accidental trauma (child abuse)
e. Vitamin C deficiency
4. Which ONE of the following nutritional deficiencies is commonly associated with easy bruising caused by impaired collagen production?
a. Iron deficiency
b. Vitamin A deficiency
c. Vitamin B6 deficiency
d. Vitamin C deficiency
e. Vitamin D deficiency
5. Which ONE of the following conditions is most characterised by episodic bruising and petechiae, often accompanied with joint pain?
a. Aplastic anaemia
b. Ehlers-Danlos syndrome
c. Henoch-Schönlein purpura
d. Liver disease
e. Vitamin C deficiency
Answers: 1.a 2.c 3.d 4.d 5.c
In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.