What can be done to address easy bruising?

Evaluation and Management of Easy Bruising

For patients presenting with easy bruising, begin with a targeted clinical assessment focusing on bleeding symptoms (epistaxis, menorrhagia, post-surgical bleeding), medication review (NSAIDs, anticoagulants, steroids), and family history of bleeding disorders, followed by initial laboratory screening with CBC with platelet count, PT, aPTT, and fibrinogen level if coagulation tests are abnormal. 1, 2

Initial Clinical Assessment

Critical History Elements

• Bleeding symptoms: Specifically evaluate for significant bleeding after surgery or dental procedures, epistaxis requiring intervention, joint hemorrhages, or menorrhagia in females 2
• Medication review: Document all medications including NSAIDs, anticoagulants, antiplatelets, steroids, and alternative therapies, as these affect both bleeding tendency and coagulation test results 1, 2
• Family history: Assess for specific bleeding disorders or ethnicity associated with higher rates of certain conditions 2
• Trauma history: Determine if bruising pattern is explained by reported trauma 2

Physical Examination Focus

• Bruising pattern and location: In children, bruising on buttocks, ears, genitals, or patterned bruising has higher specificity for abuse and warrants different evaluation 2
• Systemic illness signs: Evaluate for Ehlers-Danlos syndrome, scurvy, malignancy, infiltrative disorders, or arteriovenous malformations 2

Laboratory Testing Algorithm

Initial Screening Panel

• Complete blood count with platelet count: Essential first step to evaluate for thrombocytopenia 1, 2
• PT and aPTT: Can detect most factor deficiencies 2
• Fibrinogen level: Add if PT or aPTT are abnormal to detect fibrinogen defects 1, 2

Critical Testing Limitations

PT and aPTT do NOT reliably detect von Willebrand disease or Factor XIII deficiency, despite these being important causes of easy bruising. 1, 2 Von Willebrand disease is the most common inherited bleeding disorder with a prevalence of approximately 1 in 1000 people. 1

Common Underlying Causes

Bleeding Disorders

• Von Willebrand disease: Most common inherited bleeding disorder, presents with mucocutaneous bleeding and easy bruising 1
• Mild hemophilia: Factor VIII or IX deficiency can cause significant bruising even with mild deficiencies, and may not prolong aPTT 1
• Platelet function disorders: Require specialized testing such as platelet aggregation studies for diagnosis 1
• Factor XIII deficiency: Not detected by standard PT/aPTT screening 1

Medication-Related Causes

• Inhaled corticosteroids: Significantly increase easy bruising (47% vs 22% in controls, relative risk 2.18), with males having higher relative risk (5.80) than females (1.80) 3
• Anticoagulants and antiplatelets: Directly affect bleeding tendency 1

Connective Tissue Disorders

• Ehlers-Danlos syndrome: Easy bruising present in all subtypes due to capillary fragility and perivascular connective tissue weakness; vascular subtype can cause severe internal bleeding and arterial rupture 4

Other Medical Causes

• Vitamin K deficiency: Particularly important in infants without vitamin K prophylaxis at birth, presents with prolonged PT 1
• Liver disease/cirrhosis: Decreased production of clotting factors 1
• Immune thrombocytopenia (ITP): Transient, often self-resolving disorder with low platelet count 1

When to Refer to Hematology

Referral is indicated when: 2

• Initial laboratory evaluation indicates a bleeding disorder
• High clinical suspicion remains despite normal laboratory workup
• Specialized testing is needed (platelet function testing, von Willebrand factor studies)
• Complex cases require expert interpretation

Critical Pitfalls to Avoid

• Do not assume normal PT/aPTT rules out bleeding disorders: These tests miss von Willebrand disease, Factor XIII deficiency, and platelet function disorders 1
• Do not perform extensive testing without clinical indication: The extreme rarity of some bleeding disorders makes universal screening unreasonable 2
• Do not overlook medication effects: Certain drugs affect both bleeding tendency and test interpretation 2
• In children with concerning bruising patterns: Consider both bleeding disorders AND potential abuse, as location matters (buttocks, ears, genitals suggest abuse) 2

Special Population Considerations

Children with Cardio-Facio-Cutaneous Syndrome

Unlike Noonan syndrome, easy bruising and bleeding problems are not frequently reported in CFC. If present, screening for platelet abnormality and von Willebrand disease is recommended. 5

Pediatric ITP Management

Children with no bleeding or mild bleeding (skin manifestations only such as bruising and petechiae) should be managed with observation alone regardless of platelet count. 5