Bruising

Definition

When bleeding occurs underneath the skin, the appearance on the skin is referred to as bruising. The skin's discoloration, also known medically as purpura (due to its purple color) can be an indication of various underlying conditions.

Description

When a small blood vessel breaks, it leaks blood into the soft tissue that lies underneath the skin and bruising occurs. It is defined into three different types: Subcutaneous (under the skin); intramuscular (within the core of the underlying muscle); or periosteal (a bone bruise).

Bruising commonly occurs on the back of the hands and arms. When it does, it is known as either, solar purpura, actinic purpura, or Bateman's purpura. These bruises usually look different from those on other areas of the body. They are flat and start out red, but eventually turn purple, darken even more, and then begin to fade. These bruises do not usually occur from an injury or bumping up against something as do other bruises. These types of bruises do not have the ten-derness that normally accompanies other bruising, and they last longer, sometimes for several weeks. The damage in these areas comes after years of overexposure to the sun. The condition can worsen for individuals who take blood thinners, use alcohol, or use steroids in any form—cream, pill, or inhalant.

Demographics

Bruising can occur at any age. In the mature adult population, it can be more visible due to thinning skin. With the loss of fat and connective tissue, the aging capillaries weaken along with the tissue. The capillary walls become more fragile and more likely to rupture.

Causes and symptoms

The discoloration of bruising is often a purple or reddish mark that fades to yellow on the skin where an injury or intrusion to the skin has occurred. Many conditions can cause bruising. The most likely cause of bruising is an injury. This can be due to an accident such as a fall, sports injury, auto accident, assault, or surgery. In the case of many older adults, bruising is likely to occur more easily even without a major injury due to thin skin and medications. In the case of a serious accident or fall, internal bruising can occur due to intestinal bleeding. This situation can be life-threatening. Older adults who are physically active with exercise and athletics should take care to ensure against injury and bruising, especially if taking medications that might increase the risk of bruising. All people put themselves at risk by not heeding precautions when performing physical exercise.

Individuals diagnosed with serious blood disorders or diseases such as hemophilia, Von Willebrand's disease, Ehlers-Danlos syndrome, leukemia, immune disorders, Aplastic anemia , scurvy, or disseminated intravascular coagulation should be concerned with bruising.

Medications that increase the likelihood of bruises are blood thinning compounds such as warfarin (Coumadin), taken by many people with heart problems; aspirin ; some arthritis medicines; diuretics ; and corticosteroids. Individuals who are prescribed medications, or who take aspirin or other over-the-counter (OTC) drugs should review the possible side effects. For individuals taking anticoagulants, the bleeding that might occur from capillary damage does not stop as soon as in someone not on the medication. This causes blood to leak, resulting in bruising.

Dietary supplements such as fish oil, ginkgo, ginger and garlic have a blood-thinning effect. Because of this, especially if taken in large quantities on a regular basis, bruising may occur more easily.

The causes of bruising are not always obvious. A physician should be consulted if bruises appear on the skin for no apparent reason. Unusually large or painful bruises may indicate a more serious disorder. Also, if a person is bruising easily and experiencing abnormal bleeding from the nose, gums, intestinal tract, or there is urine in the blood, tests should be conducted to identify the cause. The problem could be a blood-clotting issue or a blood disease. Many serious diseases have bruising as a symptom, from cirrhosis of the liver to leukemia to acute kidney failure, and others.

Diagnosis

A bruise can usually be self-diagnosed if it is external. Discoloration, swelling, and pain may not appear immediately upon injury, but it usually becomes obvious within a few hours in most cases. A bruise can be an indication that a more serious injury has occurred. A physician can discern the complete diagnosis of the injury and the bruise. Optical technology is sometimes used to determine the age of a bruise. In the case of violent crime, aging a bruise using this technology could be an important tool in a resolution.

Treatment

In the case of a bruise resulting from a minor fall or accident, the affected area should be rested and cared for to help the bruise disappear and the injury to fade. For a more serious injury, especially one with severe pain, increased swelling, and fluid retention, it is not advised to drain the bruise with a needle. A physician should be consulted to evaluate the injured area and provide proper medical care. A condition known as compartment syndrome may result from increased pressure on the nerves and tissues underneath the skin. This can cause a decrease in the supply

QUESTIONS TO ASK YOUR DOCTOR

• Will my heart medication make me prone to bruising?
• Given my medical situation, how long can I expect my bruises to last?

of blood and oxygen to those tissues. In any individual compartment syndrome can be life threatening and prompt professional care is vital. Surgery may be recommended for this condition.

In older adults and people with compromised immune systems, such as those with diabetes or HIV/AIDS, infections can lead to bruising and other serious consequences. Immediate care is necessary to treat the infection and subsequent injuries.

Nutrition/Dietetic concerns

Food or food supplements that are known to have blood-thinning capabilities should be carefully monitored, especially if taking medications that might also promote bruising. Most foods, such as garlic, ginger, fish oil, and ginkgo are not likely to do serious harm if taken in small quantities. Yet individuals must consider medications and personal profiles before determining whether modification is necessary in dietary choices. Healthy immune systems and overall health and well-being remain the most crucial line of defense against any disease or condition, even bruising. If precautions are taken to maintain heart health for example, blood-thinning medications may be avoided. Genetic factors play a vital role in health and dietary concerns. People with diabetes or other immune concerns should consider consulting a nutrition expert or dietician to assist in healthy dietary control.

Therapy

When an injury causes minor swelling a cold compress or ice bag can be used to help reduce the swelling, usually for not more than 15–20 minutes. The affected area can be elevated in order to provide rest, and to aid in decreasing swelling. Once swelling has been reduced, a warm compress can be used to accelerate removal of the blood from the area, diminishing the appearance of the bruise.

KEY TERMS

Capillary —Any of the small blood vessels that connect the arteries with the veins.

Periostal —A bruise on the bone.

Subcutaneous —Below the skin.

Prognosis

Except in serious cases where other medical procedures are involved, or with ongoing medication susceptibility, bruises heal with time and rest. Most bruises last one to two weeks. Some bruising, as in the case of actinic purpura, take longer to heal. Covering the bruise with cosmetics may be desired while healing occurs. Application of alpha-hydroxy cream, or Retin-A prescription cream can also be used to lubricate and thicken the skin. In some situations, women might consult with their physicians to determine if progesterone in low dosage might help to lessen the appearance of the bruise during healing.

Prevention

Maintaining a safe environment free of clutter in order to avoid injury in the home can help to avoid bruising. When participating in physical exercise or athletics, caution should be taken to avoid injury. If prescription medications such as anticoagulants are necessary, care should be taken to avoid instances of bruising. Avoiding overexposure to the sun or the use of sunscreens can help to maintain healthy skin and prevent the effects aging might have, such as easy bruising.

Caregiver concerns

For a person at risk for bruising due to aging and medications, extra caution in physical contact should be taken. In a susceptible individual, even a bath might cause bruising, along with dressing, or assisting them with any movement. Bruises that recur and cannot be explained by medication should be investigated for possible abuse by people associated with the individual—especially if that person is in a chronic care situation or has limited mobility.

Resources

PERIODICALS

“Legal Review & Commentary: Woman Suffers Bruising on Arms After Alleged Abuse by Nursing Home Director—$825,000 Settlement.” Healthcare Risk Management December 1, 2007.

“Yellow dates bruising.” Obesity, Fitness & Wellness Week. (Nov. 27, 2004) p. 624.

“Lately I've been bruising quite easily.” Prevention. (January 2005) p. 29

OTHER

Berman, Kevin. “Purpura.” MedlinePlus. April 12, 2007 [cited April 5, 2008]. National Institutes of Health. http://www.nlm.nih.gov/medlineplus/ency/article/003232.htm.

“Bruising Hands and Arms.” Dermatologic Disease Database. Cited April 5, 2008. American Osteopathic College of Dermatology. http://www.aocd.org/skin/dermatologic_diseases/bruising_hand_and.html.

“Easy Bruising: Common as You Age.” Mayo Clinic. May 25, 2007 [cited April 5, 2008]. http://www.mayoclinic.com/print/easy-bruising/HQ00355/METHOD=print.

“Mature Skin.” 2008 [cited April 5, 2008]. American Academy of Dermatology. http://www.aad.org/public/publications/pamphlets/sun_mature.html.

Van Voorhees, Benjamin. “Bruise.” MedlinePlus. May 17, 2007 [cited April 5, 2008]. National Library of Medicine. http://www.nlm.nih.gov/medlineplus/ency/article/007213.htm

ORGANIZATIONS

American Academy of Dermatology, 1350 I Street, NW, #870, Washington, D.C., 20005–4355, (202) 842-3555, (202) 843-4355, http://www.aad.org.

American Diabetes Association, 1701 Beauregard Street, Alexandria, VA, 22311, (800) 342-2383, http://www.ada.org.

Mayo Clinic, 200 First Street, NW, Rochester, MN, 55905, (507) 284-2511, http://www.mayoclinic.com.

National Institute on Aging, National Institutes of Health, Building 31, Room 5C27, 31 Center Drive, Bethesda, MD, 20892, http://www.nia.nih.org.

Jane Elizabeth Spear