From the Guidelines
The workup for spontaneous skin bruising in an otherwise healthy adult should begin with a thorough history and physical examination, including laboratory testing to rule out underlying bleeding disorders, as suggested by the 2008 NHLBI/NIH guidelines 1. When evaluating spontaneous skin bruising, it is essential to consider the patient's medical history, including medication use, supplement use, and family history of bleeding disorders.
- Key elements to assess include:
- Medication use, particularly anticoagulants like warfarin, DOACs, aspirin, or NSAIDs
- Supplement use, especially fish oil, vitamin E, ginkgo
- Alcohol consumption
- Family history of bleeding disorders A physical examination should document the pattern, distribution, and size of bruises and look for other signs of bleeding, such as petechiae or purpura, as well as evidence of liver disease, splenomegaly, joint and skin laxity, telangiectasia, signs of anemia, or anatomic lesions on gynecologic examination 1. Initial laboratory testing should include a complete blood count (CBC) with platelet count, peripheral blood smear, prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen level.
- If these are normal but clinical suspicion remains high, additional testing may include:
- von Willebrand factor antigen and activity
- factor VIII and IX levels
- platelet function studies
- bleeding time For recurrent or severe bruising, referral to a hematologist is appropriate, as most spontaneous bruising is benign and related to minor trauma that wasn't noticed, but systematic evaluation helps identify the small percentage of cases that represent underlying hematologic disorders requiring specific treatment.
From the Research
Evaluation of Spontaneous Skin Bruising
- Spontaneous skin bruising in otherwise healthy adults can be caused by various factors, including bleeding disorders such as von Willebrand disease 2, 3, 4, 5.
- The initial evaluation of easy bruising and bleeding includes a comprehensive history, physical examination, and patient-provided photographs to help identify causes of abnormal bleeding and bruising 6.
- Laboratory testing, such as a complete blood cell count, peripheral blood smear, prothrombin time (PT), international normalized ratio, activated partial thromboplastin time (aPTT), and fibrinogen, can help diagnose bleeding disorders 6.
Bleeding Disorders
- Von Willebrand disease is a common inherited bleeding disorder characterized by a deficiency or dysfunction of von Willebrand factor, which is essential for platelet adhesion and blood coagulation 2, 3, 4, 5.
- Desmopressin is a synthetic analogue of the antidiuretic hormone L-arginine vasopressin, which can raise circulating levels of factor VIII and von Willebrand factor, making it a useful treatment for mild and moderate hemophilia and von Willebrand disease 2, 3, 4, 5.
- The treatment of von Willebrand disease aims to correct the dual defect of hemostasis, including abnormal platelet adhesion and coagulation, which can be achieved by administering desmopressin or plasma concentrates containing von Willebrand factor and factor VIII 2, 4.
Diagnostic Approach
- A bleeding assessment tool and a comprehensive history, physical examination, and patient-provided photographs can help identify causes of abnormal bleeding and bruising 6.
- Initial laboratory testing, including PT, aPTT, and fibrinogen, can help diagnose bleeding disorders, and normal PT and aPTT results may indicate a platelet disorder 6.
- Consultation with a hematologist is recommended when initial evaluation indicates a bleeding disorder or when suspicion remains high despite a normal laboratory workup result 6.