Topical Treatment for Superficial Hematomas
For superficial hematomas (bruises), apply localized cold therapy with or without pressure as the primary first-aid intervention; topical arnica 20% ointment may provide modest additional benefit for accelerating bruise resolution, though evidence remains limited.
Primary Recommendation: Cold Therapy
- Apply localized cold therapy (such as an instant cold pack) directly to the hematoma site, which may be beneficial for hemostasis in closed bleeding. 1
- Cold therapy should be applied to a relatively small, limited-size injury area to avoid hypothermia risk, particularly in pediatric patients. 1
- Pressure may be combined with cold therapy for enhanced hemostasis, though the evidence quality is very low. 1
Topical Arnica as an Adjunct
- Topical 20% arnica ointment applied twice daily under occlusion demonstrated statistically significant acceleration of bruise resolution compared to placebo in laser-induced bruising (mean improvement greater than white petrolatum, P=0.003). 2
- Lower concentration arnica formulations (such as standard arnica gel) showed no significant difference from placebo in preventing or resolving bruising (P=0.496 for prevention, P=0.359 for post-treatment). 3
- Arnica is FDA-listed as a topical relief cream, supporting its availability for over-the-counter use. 4
Important Caveat About Arnica Evidence
The positive study used 20% arnica concentration under occlusion on laser-induced bruising in controlled conditions 2, while the negative study used standard arnica gel on similar laser bruising 3. The concentration and formulation appear critical—only high-concentration arnica (20%) showed benefit.
When Hematomas Require More Than Topical Treatment
- Large hematomas with overlying skin at risk for necrosis due to tissue pressure require prompt operative evacuation, not topical therapy alone. 5
- Accumulation of blood can cause cellular and biochemical changes leading to tissue ischemia and necrosis even without obvious increased pressure. 5
- Spontaneous cervical hematomas or those associated with anticoagulation require evaluation for airway compromise and may need surgical intervention. 6
What NOT to Use
- Standard hemostatic agents (collagen-based, gelatin-based, fibrin sealants, chitosan products like Axiostat) are designed for active bleeding control during surgery or trauma, not for closed hematomas/bruises. 1, 7, 8
- These surgical hemostatic agents require direct contact with bleeding tissue and are inappropriate for intact skin overlying a hematoma. 1
Practical Algorithm
- Assess hematoma size and overlying skin integrity: If large with skin compromise or neurovascular symptoms → refer for surgical evaluation 5
- For simple superficial bruising: Apply cold pack to limited area with gentle pressure 1
- Consider adding 20% arnica ointment twice daily if available and faster cosmetic resolution is desired 2
- Avoid lower-concentration arnica products as they lack evidence of efficacy 3
- Ensure tetanus prophylaxis is current if any associated skin break 9