Ecchymosis, commonly known as bruising, isn’t typically worrisome, but people do wonder, Why do I bruise so easily? especially as we get older. For some of us, there is no underlying reason…while the cause for others can be anywhere on the spectrum from relatively harmless to, rarely, life-threatening. Bottom Line Personal asked hematologist-oncologist Trevor Bayliss MD, medical director of the Phelps Cancer Center, what are the most common causes of bruising.
The most common reason that people bruise easily. The very purpose of an anticoagulant medication—to inhibit blood clots—makes blood thinners a leading cause of bruising and increases the risk of bruising from even a minor bump. This is true whether you’re on daily baby aspirin, apixaban, rivaroxaban, warfarin or even fish oil in large doses. Even NSAIDs such as ibuprofen also inhibit platelets’ clotting ability. The effect becomes apparent in as few as five to seven days after starting an anticoagulant. Interestingly, that coincides with the lifespan of a platelet and helps explain why people are told to stop taking certain drugs a week before any surgery—to avoid any excess bleeding. During this period, dying platelets will finish their cycle and new ones, uninhibited by the medications, will be produced.
Bruising is more common as we age because of the slow but steady loss of collagen, which provides structure, support and strength to your skin, muscles, bones and more. Collagen is intimately involved in hemostasis, the body’s ability to stop a bleed and keep blood within vessels. As we lose collagen, not only does our skin develop wrinkles, there also is a natural increase in the tendency to bruise easily.
Many of us have heard of hemophilia, but it is actually quite rare. The most common bleeding disorder in the US is von Willebrand disease, characterized by a lack of the clotting protein von Willebrand factor. The severity of von Willebrand disease varies depending on the individual’s level of the factor. It can be so mild that you are not even aware you have it or quite severe. Severe cases usually start in childhood or early adulthood. Other bleeding disorders, including hemophilia, also are related to levels of specific clotting factors. Another less common bleeding disorder is qualitative platelet disorder (QPD), in which platelets don’t function as they should because of alterations to their structure that lead to poor clotting. These disorders often are managed with medications and, if needed, transfusions.
Liver disease can stymie clotting factors and promote what appears to be unexplained bruising, as can kidney disease, primarily because it can worsen other risk factors that occur with older age, such as thinner skin and more fragile capillaries. In most cases, bruising isn’t the first clue to one of these conditions, so testing might be warranted if it has been a number of years since you had a lab test to check your creatinine levels, which indicate kidney function, or a history of hepatitis or heavy alcohol consumption. Bruising easily also may be due to collagen vascular disease, the umbrella name for a group of conditions that cause chronic inflammation in connective tissues. Many of these are autoimmune diseases, including rheumatoid arthritis, lupus, scleroderma, Sjögren syndrome and ankylosing spondylitis (a type of arthritis that causes inflammation in the spine). More rare are genetic collagen vascular diseases such as Ehlers-Danlos syndrome and Marfan syndrome. The most prominent symptoms are far more serious than bruising, but bruising is a side effect of faulty collagen.
Some types of cancers increase bleeding risk—not only blood cancers, but also lung, prostate and colorectal cancers. Cancer treatments that lower platelet counts also can put you at greater risk of bruising.
Unexplained bruising can be concerning. If you’re bruising without having experienced any memorable trauma…if the bruises are generally larger than the size of a quarter…and/or if they’re occurring on areas of the body that aren’t prone to bumping and banging (such as the abdomen rather than forearms and shins), contact your doctor or a hematologist, a specialist in disorders involving blood, bone marrow and the lymphatic system.
The doctor will start by taking a detailed medical history. Hematologists can quantify bleeding with a scale such as the condensed Vicenza-based BAT (bleeding assessment tool). Points are assigned for various bleeding episodes and the level of medical intervention needed to resolve each one.
One suspicious sign is having a significant bleed after a tooth extraction, to the point that you needed extra packing or another stitch to stop it. In fact, having your wisdom teeth removed is a common way that people find out they have a bleeding disorder, especially for boys since this often is their first major bleeding episode. Girls with bleeding disorders typically have extremely heavy periods from the onset of menstruation—the blood loss can be severe enough to lead to anemia. Other examples: Very heavy bleeding during a surgery or childbirth, to the point of needing a transfusion…bleeding easily from a cut, to the point of needing stitches. Each of these events carry a weighted number of points.
If you’re assessed a high score, there’s a strong likelihood of an underlying bleeding disorder. The next step is to identify which disorder it might be, often with a blood test that measures platelet function. To avoid skewed results, don’t take any anticlotting drugs, including NSAIDs, for one week before the test. People who simply bruise easily might score a single point on the BAT. Without any significant bleeding episodes in their medical history, it’s very unlikely that they have any underlying bleeding disorder. Bruising easily is just part of their body’s makeup. It’s also possible for a bruise to take longer than a week to go away, but how long a bruise lasts isn’t scored on the BAT so without any other factors, that too will be considered normal for them.
A bruise—also known as an ecchymosis—forms when tiny capillaries that you can’t really see with the naked eye get ruptured. They’re not the larger veins that run through your wrist and hand, for instance (although you could get a pretty good sized bruise from even a little ding on one of those veins). Ruptured capillaries happen on a micro level throughout the day and the body almost instantaneously reabsorbs the blood. But if a bang on your thigh, as an example, is big enough, the process will happen slowly enough that you’ll notice.
As hemoglobin accumulates under the skin in the soft tissue, you’ll first see that telltale purplish color. Then, over time, the bruise turns shades of green and yellow—that’s called hemosiderin deposition, the remains of the unabsorbed blood cells. Slowly your immune system scavenges those dead cells, cleaning them up…and you’re back to normal.
You may be able to limit the extent of the bruise somewhat by applying a cold pack to the area as soon as you realize that you banged into something. This helps constrict vessels. If there’s no cold pack handy, apply pressure—this mechanical force will help close capillaries around the area and lessen the bruising.
Most of the time, you don’t need to see a doctor about a bruise, but there are times that you should contact your doctor right away…
If you have a bleeding disorder or are on a blood thinner and get a bruise, call your health-care provider or follow the protocol that he/she may have already gone over with you.
If you fall and hit your head or if you get hit in the head by accident, say from a foul ball at a baseball game or even a can falling on you from a high shelf, you may need to be evaluated for a concussion, even if you feel fine in the moment. If you have confusion or feel disoriented, that’s even more reason to get swift medical attention.
If you develop a hematoma (a collection of blood larger than the average bruise), seek medical attention right away. The affected area will swell—you’ll get a lump or bulge like the classic goose egg on the head you see in comics and cartoons. (The area around a run-of-the-mill bruise will usually be flat, not raised.) Call your doctor for advice—he may suggest going to the ER or an imaging center to help make an evaluation and decide on treatment.
