Go back


    Ecchymosis – Diagnosis & Treatment

    Dermatology, Hematological / Oncological

    Last Updated May 03, 2021
    Read Disclaimer
    By Julian Marsden, Neil Thurley


    Bruising (ecchymosis) results from the extravasation of blood beneath intact skin, most often due to trauma.

    • When discordant with the degree of trauma may be caused by an underlying bleeding disorder.1,2
    • Up to 55% of otherwise healthy individuals will present with easy bruising.1,2


    Major etiologies of bruising include:1,2

    • Trauma: accidental, non-accidental.
    • Vascular disorders: senile purpura, simple purpura, connective tissue diseases, vitamin C deficiency.
    • Platelet disorders: immune thrombocytopenia, thrombotic thrombocytopenic purpura, aplastic anemia, hematologic malignancies, congenital/inherited platelet disorders.
    • Coagulation disorders: Von Willebrand disease, hemophilia A, hemophilia B, liver disease, vitamin K deficiency.
    • Drugs: alcohol, corticosteroids, aspirin, NSAIDs, clopidogrel, SSRIs, certain antibiotics, thiazide diuretics, warfarin, heparin, DOACs.

    Diagnostic Process


    • Consider relevant medical conditions, medications, social history, and family history.1,2,3
    • Consider including a specific bleeding/bruising history. The International Society on Thrombosis and Hemostasis Bleeding Assessment Tool may be used to guide questioning.1,2,3
    • Rule out abuse in pediatric, geriatric, and vulnerable populations.
    • Red flags for bruises associated with physical abuse include:1,2,3
      • Bruises discordant with the given explanation.
      • Bruises on not yet mobile children.
      • Bruises on torso, buttocks, ears, or neck.
      • Bruises that are large, numerous, clustered or patterned in the shape of a striking implement.


    • Bruises location, size, shape, number, etc., joints, abdomen, head, neck, and lymph nodes.
    • Normal bruises tend to be small, relatively round, have non-distinct borders, and appear over bony prominences on the anterior surface of the body.1,2
    • Bruises indicative of an underlying bleeding disorder may be persistent, spontaneous, numerous (>5), large (>1cm), or appear in abnormal locations (e.g. trunk, back, and face).1,2
    • Mucocutaneous bleeding suggests vasculature, Von Willebrand factor, or platelet disorders.1,2
    • Petechiae suggests severe thrombocytopenia.1,2,3
    • Purpura suggests thrombocytopenia or vasculature disorders.1,2
    • Hemarthroses or muscle hematomas are indicative of coagulation factor disorders (e.g. hemophilia).1,2,3
    • Joint or skin laxity may indicate a connective tissue disorder.1,2,3
    • Hepatosplenomegaly may indicate liver or systemic disease.1,2,3

    Laboratory Investigations


    • Complete blood count (CBC) with differential.
    • Prothrombin time (PT) or international normalized ratio (INR).
    • Activated partial thromboplastin time (PTT).
    • Liver, renal, and thyroid function tests.

    Recommended Treatment

    Bruising with no suspicion of an underlying bleeding disorder can be treated with simple analgesia (acetaminophen, ibuprofen, etc.) and patient reassurance.2

    • Clinically stable patients with continued unexplained bruising/bleeding, with or without abnormal laboratory investigations, should be referred to a hematologist.2 Urgency relies on clinical judgment of severity.
    • Admit patients with significant active bleeding that is unresponsive to initial management (e.g. compression).2 Admit vulnerable patients if abuse is suspected; abuse should be reported to the appropriate government agency.2
    • Medications suspected to be causing bruising should be discontinued, if possible.2

    Related Information

    Reference List

    Relevant Resources


    View all Resources


    COMMENTS (0)

    Add public comment…