What can be done to address easy bruiseability?

Management of Easy Bruising

The initial approach to easy bruising requires a targeted clinical assessment focusing on medication review, bleeding history, and selective laboratory testing—with the understanding that most patients with isolated easy bruising and normal screening tests do not require correction of laboratory abnormalities or extensive intervention. 1, 2

Immediate Clinical Assessment

Medication Review (Critical First Step)

• Document all medications that increase bleeding risk: anticoagulants (warfarin, DOACs), antiplatelet agents, NSAIDs, corticosteroids (including inhaled forms), and alternative therapies 1, 2
• Inhaled corticosteroids cause easy bruising in 47% of users (relative risk 2.18), particularly in older patients on higher doses—males have 5.8-fold increased risk compared to 1.8-fold in females 3
• For patients on anticoagulants with major bleeding, consider reversal: 4-factor PCC with vitamin K for warfarin, idarucizumab 5g IV for dabigatran, andexanet alfa for apixaban/rivaroxaban 1
• Divalproex sodium requires platelet monitoring every 6 months 1

Targeted Bleeding History

• Ask specifically about: significant bleeding after surgery/dental procedures, epistaxis requiring intervention, joint hemorrhages, menorrhagia in females 2
• Assess family history for specific bleeding disorders and ethnicity associated with higher rates of certain conditions 2
• Evaluate trauma history to determine if bruising pattern matches reported trauma 2

Physical Examination Focus

• Bruising location matters: buttocks, ears, genitals, or patterned bruising has higher specificity for abuse in children and requires different evaluation 2
• Look for systemic illness signs: Ehlers-Danlos syndrome features (joint hypermobility, skin hyperextensibility), scurvy, malignancy, arteriovenous malformations 2, 4

Laboratory Testing Algorithm

Initial Screening Panel

• Complete blood count with platelet count and peripheral blood smear 2
• PT (prothrombin time) and aPTT (activated partial thromboplastin time) 2
• Fibrinogen level if PT or aPTT are abnormal 2

Critical Testing Limitations to Recognize

• PT and aPTT do NOT reliably detect von Willebrand disease (the most common inherited bleeding disorder, prevalence 1 in 1000) or Factor XIII deficiency 2, 5
• Normal platelet count does not exclude platelet function disorders—specialized testing like platelet aggregation studies may be needed 5, 6
• Elevated platelet counts with easy bruising suggest reactive thrombocytosis requiring platelet function evaluation 5

Additional Testing Based on Clinical Context

• Vitamin K deficiency testing in infants without birth prophylaxis or with prolonged PT 2
• Platelet function analyzer (PFA-100) can screen for platelet disorders but requires hematology consultation for interpretation 2
• Platelet IgG levels if autoimmune etiology suspected (elevated in thyroid disease, correlates with easy bruising) 7

Management by Clinical Scenario

For Patients with Abnormal Laboratory Tests

• In cirrhosis patients with abnormal INR, APTT, platelet count, or fibrinogen: do NOT attempt correction with blood products or factor concentrates to prevent spontaneous bleeding—this is not recommended and lacks evidence 8
• Vitamin K administration (especially oral or subcutaneous) does not improve INR in chronic liver disease 8

For Patients with Normal Laboratory Tests

• Most patients with isolated easy bruising and normal screening tests have either normal platelet function (Type I, 60% of cases) or mild platelet dysfunction (Type II, 40% of cases) 6
• Elevated megathrombocyte numbers occur in 60-71% and antiplatelet antibodies in 30-38%, suggesting possible autoimmune etiology 6

Practical Measures to Minimize Bruising

• Apply pressure for 5-10 seconds to injection sites to minimize injection-related bruising 1
• Optimize metabolic control in glycogen storage disease type I, as platelet defects are secondary to metabolic abnormalities and improve with better control 8

Indications for Hematology Referral

Refer when: 2

• Initial laboratory evaluation indicates a bleeding disorder
• High clinical suspicion persists despite normal laboratory workup
• Specialized testing needed (platelet function studies, von Willebrand panel, Factor XIII assay)
• Complex cases requiring expert interpretation

Special Population Considerations

Immune Checkpoint Inhibitor Therapy

• Easy bruising may indicate immune-related thrombocytopenia or acquired hemophilia A—requires hematology consultation, may need corticosteroids, IVIG, or factor replacement 1

Cardio-Facio-Cutaneous Syndrome

• Screen for von Willebrand disease and thrombocytopenia 1

Glycogen Storage Disease Type I

• Bleeding tendency from impaired platelet function and acquired von Willebrand-like disease improves with metabolic control 8
• Menorrhagia common in reproductive-age females 8

Ehlers-Danlos Syndrome (Vascular Type)

• Easy bruising present in all subtypes due to capillary fragility; vascular type (collagen III defect) has risk of arterial rupture and severe internal bleeding 4
• Haematological studies typically normal except Hess test (capillary fragility test) 4

Common Pitfalls to Avoid

• Do not perform extensive testing without clinical indication—universal screening for rare bleeding disorders is unreasonable 2
• Do not assume normal PT/aPTT rules out bleeding disorders—these miss von Willebrand disease, Factor XIII deficiency, and platelet function disorders 5
• Do not overlook medication effects, particularly inhaled corticosteroids which are often not considered systemic therapy 3
• Do not attempt to "correct" abnormal coagulation tests in cirrhosis patients to prevent spontaneous bleeding—this practice lacks evidence and is not recommended 8