What causes easy bruising and how is it treated?

Easy Bruising: Causes and Management

Easy bruising is most commonly caused by platelet disorders, coagulation factor deficiencies, or connective tissue disorders, and treatment should be directed at the underlying cause while focusing on preventing serious bleeding complications that could impact mortality and quality of life. 1

Diagnostic Approach

Initial Assessment

• Bleeding history evaluation:

  • Pattern and location of bruising (bruising on buttocks, ears, and genitals raises concern for abuse) 2
  • Family history of bleeding disorders (98% of specialists consider this critical) 1
  • Medication use, especially NSAIDs and over-the-counter drugs (88% of specialists document this) 1
  • Previous excessive bleeding after surgery, dental procedures, or childbirth 1
  • Spontaneous bruising vs. bruising with minimal trauma

• Physical examination:

  • Distribution and pattern of bruises
  • Assessment for hypermobility (suggests connective tissue disorders) 1
  • Mucocutaneous bleeding (suggests platelet dysfunction) 3
  • Hemarthroses or hematomas (suggests coagulopathy) 3

Laboratory Testing

1. First-line tests: 1, 3

   • Complete blood count (CBC) with platelet count
   • Peripheral blood smear
   • Prothrombin time (PT)
   • Activated partial thromboplastin time (aPTT)

2. Interpretation of initial results:

   • Normal PT and aPTT: Consider platelet disorder (most commonly von Willebrand disease)
   • Normal PT, prolonged aPTT: Deficit in intrinsic pathway (perform mixing study)
   • Abnormal PT, normal aPTT: Consider vitamin K deficiency
   • Prolonged PT and aPTT: Consider liver failure or disseminated intravascular coagulation

3. Additional testing for suspected von Willebrand disease: 1

   • VWF antigen
   • VWF ristocetin cofactor activity
   • Factor VIII coagulant activity

Common Causes of Easy Bruising

1. Platelet Disorders

• Von Willebrand disease:

  • Most common inherited bleeding disorder
  • Not reliably detected by PT/aPTT screening 1
  • Requires specific VWF testing

• Platelet function disorders:

  • May have normal platelet count but abnormal function
  • Can be acquired (medications) or inherited (Bernard Soulier syndrome, Glanzmann thrombasthenia) 1

2. Coagulation Factor Deficiencies

• Hemophilia A and B:

  • Mild forms may have normal aPTT but still cause significant bleeding 1
  • Factor VIII or IX deficiency

• Factor XIII deficiency:

  • Not detected by routine PT/aPTT
  • Can cause significant bleeding 1

3. Connective Tissue Disorders

• Ehlers-Danlos syndrome:

  • Easy bruising due to fragility of capillaries and perivascular connective tissues 4
  • Vascular subtype (Type IV) can lead to severe internal bleeding or premature death 2
  • Haematological studies usually normal except for capillary fragility tests 4

• Loeys-Dietz syndrome:

  • Characterized by arterial tortuosity and aneurysms
  • Can lead to arterial dissection 2

4. Other Causes

• Easy bruising syndrome:

  • Type I: Normal to supranormal platelet function
  • Type II: Abnormal platelet function with impaired aggregation 5
  • Predominantly affects women

• Medication-induced:

  • Antiplatelet agents (aspirin, NSAIDs)
  • Anticoagulants
  • Some antibiotics and antidepressants

Treatment Approach

1. For Von Willebrand Disease

• First-line therapy: Desmopressin (DDAVP) 0.3 μg/kg IV for mild to moderate Type 1 1
• For Type 2B, Type 3, and severe forms: VWF-containing factor concentrates 1
• Target VWF activity level:
  • Minimum 50 IU/dL for adequate hemostasis
  • ≥80 IU/dL for history of severe bleeding 1

2. For Platelet Function Disorders

• Avoid medications that impair platelet function
• Platelet transfusions for severe bleeding
• Antifibrinolytic agents (tranexamic acid)

3. For Connective Tissue Disorders

• Careful tissue handling during surgical procedures 2
• Avoidance of contact sports and activities with high risk of trauma
• Genetic counseling

4. General Management

• Identify and treat underlying cause
• Avoid medications that impair hemostasis when possible
• Apply pressure to bleeding sites
• Consider iron supplementation if anemia develops from chronic blood loss

Special Considerations

Children

• Evaluate for non-accidental trauma when bruising pattern is suspicious 2
• The following factors generally exclude the need for bleeding disorder evaluation:
  • Caregiver's description of trauma sufficiently explains bruising
  • Child provides history that explains bruising
  • Abusive object or hand-patterned bruising is present 2

Women

• Women commonly present with easy bruising complaints 6
• Evaluate for hormonal influences on bleeding tendency
• During pregnancy, target VWF:RCo ≥50 IU/dL for vaginal delivery and ≥80 IU/dL for cesarean section 1

Elderly

• Consider age-related capillary fragility
• Review medications for potential interactions
• Evaluate for underlying malignancy or liver disease

When to Refer to a Specialist

• Abnormal laboratory findings despite initial workup
• Strong family history of bleeding disorders
• Recurrent or severe bleeding episodes
• Suspected rare bleeding disorders requiring specialized testing 3

Remember that while easy bruising is often benign, it can sometimes signal a serious underlying condition that requires prompt diagnosis and management to prevent morbidity and mortality.