What are the common causes of easy bruising in a 50‑year‑old male?

Common Causes of Easy Bruising in a 50-Year-Old Male

In a 50-year-old male with easy bruising, the most common causes are medications (anticoagulants, antiplatelets, NSAIDs, steroids), liver disease, senile purpura from aging blood vessels, and undiagnosed bleeding disorders—particularly von Willebrand disease, which affects 1 in 1000 people regardless of age. 1

Most Likely Causes in This Age Group

Medication-Related Causes

• Anticoagulants, antiplatelets, NSAIDs, steroids, and certain antibiotics are among the most common culprits and should be the first consideration in any adult with new-onset easy bruising 1
• A comprehensive medication review including over-the-counter NSAIDs is essential, as these directly affect bleeding tendency and coagulation 2

Age-Related Vascular Changes

• Senile purpura occurs from thinning of blood vessels and skin with aging, becoming increasingly common in middle-aged and older adults 1
• This represents fragility of capillaries and perivascular connective tissues, similar to what occurs in collagen disorders 3

Liver Disease

• Cirrhosis and other forms of liver disease lead to decreased production of clotting factors, manifesting as spontaneous bruising 1
• Abnormal laboratory tests (INR, aPTT, platelet count, fibrinogen) are common in cirrhosis, though they don't necessarily predict spontaneous bleeding 1

Undiagnosed Bleeding Disorders

• Von Willebrand disease is the most common inherited bleeding disorder (prevalence 1 in 1000) and can present at any age with mucocutaneous bleeding and easy bruising 1
• Many adults remain undiagnosed until a significant bleeding challenge occurs 4
• Hemophilia (Factor VIII or IX deficiency) is particularly relevant in males and can cause significant bruising even with mild deficiencies 1

Less Common But Important Causes

Hematologic Malignancies

• Malignancies and infiltrative disorders can cause thrombocytopenia or coagulation abnormalities leading to bruising 1

Platelet Disorders

• Immune thrombocytopenia (ITP) can occur in adults as a transient or chronic condition characterized by low platelet count 1
• Platelet function disorders can present with normal platelet counts but abnormal function, requiring specialized testing 1

Connective Tissue Disorders

• Ehlers-Danlos syndrome, particularly the vascular subtype, causes easy bruising due to collagen defects affecting blood vessel walls 3
• Easy bruising is present to a variable degree in all EDS subtypes due to capillary and perivascular connective tissue fragility 3

Diagnostic Approach

Initial Laboratory Evaluation

• Start with CBC with platelet count, PT, aPTT, and peripheral blood smear to detect most common abnormalities 1, 5
• If PT or aPTT are abnormal, add fibrinogen level 2

Interpretation of Initial Tests

• Normal PT and aPTT with easy bruising strongly suggests von Willebrand disease or platelet function disorder, as these tests do not reliably detect VWD, Factor XIII deficiency, or platelet disorders 1, 4
• Prolonged PT with normal aPTT suggests extrinsic pathway disorder (Factor VII deficiency, vitamin K deficiency, early liver disease) 5
• Normal PT with prolonged aPTT indicates intrinsic pathway deficit; perform mixing study 4
• Both PT and aPTT prolonged warrants evaluation for liver disease, vitamin K deficiency, or DIC 1

When to Pursue Further Testing

• If clinical suspicion remains high despite normal screening tests, refer to hematology for specialized testing including VWD-specific testing (VWF antigen, VWF ristocetin cofactor activity, Factor VIII coagulant activity) and platelet function studies 1, 5
• Factor XIII deficiency is not detected by standard PT/aPTT screening but can cause significant bruising 1

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 overlook medication effects, including over-the-counter NSAIDs and supplements 2
• Coagulation tests are very sensitive to specimen handling; false-positive results from inappropriate handling are common, so use experienced laboratories 1
• Do not assume normal platelet count excludes platelet disorders, as qualitative platelet defects require specialized testing 2
• aPTT can be falsely prolonged with lupus anticoagulant or Factor XII deficiency (which does not indicate a true bleeding disorder) 1

Location and Pattern of Bruising

• Bruises on soft-tissue areas (thighs, upper arms, trunk) are more indicative of underlying bleeding disorders than bruises over bony prominences from normal activity 1
• This distinction helps differentiate pathologic from physiologic bruising 1