Bruising

Source:
Clinical Knowledge Summaries - CKS
Publication date:
01 March 2016

Abstract

Bruising Last revised in March 2016 Next planned review by December 2021 Summary Back to topBruising: Summary A bruise is a haematoma which forms due to bleeding under intact skin into subcutaneous tissue, due to vascular damage or injury.Bruising usually occurs as a result of accidental trauma, but may be non-accidental.Bruising is the most common injury sustained by children who have been subject to physical abuse.Excessive bruising, or bruising which occurs as a result of minimal or no recognized trauma, may be caused, or exacerbated by, an underlying bleeding disorder or medical condition, including:Vascular disorders (for example senile or simple purpura).Platelet disorders (for example idiopathic thrombocytopenic purpura, leukaemia, or liver disease).Coagulation disorders (for example haemophilia, vitamin K deficiency, or von Willebrand disease).Drugs (such as corticosteroids, warfarin, and alcohol).The presence of a bleeding disorder or underlying medical condition does not rule out non-accidental injury as a cause of abnormal bruising.Assessment of a person with bruising involves:Asking about symptoms suggesting an underlying platelet or coagulation disorder, such as nosebleeds or menorrhagia.Asking about possible underlying medical causes.Asking about alcohol and drugs.Asking about a family history of a known bleeding disorder, or a tendency to bruise or bleed easily or spontaneously.Assessing the location and pattern of bruising in the context of the person's age, mobility and developmental status, and the explanation for injury (if any).Investigation of an adult with unexplained bruising, bleeding, petechiae, or hepatosplenomegaly should include:A very urgent full blood count and blood film (within 48 hours) to assess for leukaemia.A clotting screen.Liver, renal, and thyroid function tests, depending on clinical judgement.Investigation of a child or young person with unexplained bruising or bleeding should include:A very urgent full blood count and blood film (within 48 hours) to assess for leukaemia.Blood results may be normal in people with mild coagulation and platelet disorders.If non-accidental injury is suspected, immediate referral should be made to the most appropriate agency.Referral for immediate specialist assessment of leukaemia should be arranged for a child or young person if they have:Unexplained petechiae orHepatosplenomegaly orFull blood count results suggestive of leukaemia.Referral for urgent specialist assessment of neuroblastoma (within 48 hours) should be arranged for a child if they have:A palpable abdominal mass orAn unexplained enlarged abdominal organ.All other children should be discussed with a paediatrician or paediatric haematologist, to arrange further investigations.Referral for immediate specialist assessment should be arranged for an adult if they have:Full blood count results suggestive of leukaemia.For all other adults, referral to a haematologist should be arranged, the urgency depending on clinical judgement, if there is:A low platelet count.An abnormal clotting screen.Normal blood results in primary care but a bleeding disorder is still suspected. Have I got the right topic? Back to topHave I got the right topic? From age 1 month onwards.This CKS topic covers the assessment and management of bruising (including normal and abnormal bruising) in children and adults.This CKS topic does not cover the assessment or management of other types of purpura, or the management of underlying causes of abnormal bruising.There are separate CKS topics on Anticoagulation - oral, Child maltreatment - recognition and management, Falls - risk assessment, and Haematological cancers - recognition and referral.The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare. How up-to-date is this topic? Back to topHow up-to-date is this topic? Back to top Changes Changes March 2016 — reviewed. A literature search was conducted in February 2016 to identify evidence-based guidelines, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to recommendations have been made, but additional emphasis has been put on adults with possible safeguarding issues, such as the elderly. Back to top Previous changes Previous changes December to March 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence. Back to top Update Update Back to top New evidence New evidence Evidence-based guidelinesNo new evidence-based guidelines since 1 March 2016.HTAs (Health Technology Assessments)No new HTAs since 1 March 2016.Economic AppraisalsNo new economic appraisals relevant to England since 1 March 2016.Systematic reviews and meta-analysesNo new systematic reviews or meta-analysis since 1 March 2016.Primary evidenceNo new randomized controlled trials published in the major journals since 1 March 2016.  Back to top New policies New policies No new national policies or guidelines since 1 March 2016. Back to top New safety alerts New safety alerts No new safety alerts since 1 March 2016. Back to top Changes in product availability Changes in product availability No changes in product availability since 1 March 2016.  Goals and outcome measures Back to topGoals and outcome measures Back to top Goals Goals To support primary healthcare professionals to:Make a diagnosis of normal or abnormal bruising.Arrange appropriate investigations where necessary.Identify red flags for possible non-accidental bruising, and manage appropriately.Admit or refer people with abnormal bruising, when appropriate. Back to top Outcome measures Outcome measures No outcome measures were found during the review of this topic. Back to top Audit criteria Audit criteria No audit criteria were found during the review of this topic. Back to top QOF indicators QOF indicators No QOF indicators were found during the review of this topic. Back to top QIPP - Options for local implementation QIPP - Options for local implementation No QIPP indicators were found during the review of this topic. Back to top NICE Quality standards NICE quality standards No NICE quality standards were found during the review of this topic. Background information Back to topBackground information Back to top Definition What is it? A bruise is a haematoma which forms due to bleeding under intact skin into subcutaneous tissue, due to vascular damage or injury.A bruise typically initially appears as a red discolouration which does not blanch on pressure. The colour gradually darkens to purple, fades to a brownish yellow, and usually disappears within 2–3 weeks. These colour changes may be more difficult to assess in people with darker skin tones.The colour of a bruise is not a reliable indicator of the age of a bruise, and there is a wide variability in the appearance and healing of bruises, both among individuals and among bruises on the same person.Easy bruising implies that no significant trauma has occurred to the skin or subcutaneous tissue, and bruises are larger or more frequently seen than normal [BMJ Best Practice, 2015].A survey of bleeding histories of 500 healthy people found that 18% reported easy bruising [Mauer, 2011].[Maguire et al, 2005; Khair and Liesner, 2006; Valente and Abramson, 2006; Ward et al, 2013; Neutze and Roque, 2016] Back to top Causes What causes it? Bruising usually occurs as a result of trauma, which is usually accidental but may be non-accidental.Bruising is the most common injury sustained by children who have been subject to physical abuse.Excessive bruising, or bruising which occurs as a result of minimal or no recognized trauma, may be caused by, or exacerbated by, an underlying bleeding disorder or medical condition, including:Vascular disorders.Platelet disorders.Coagulation disorders.Drugs.Be aware that the presence of a bleeding disorder or other underlying medical condition does not rule out non-accidental injury as a cause of abnormal bruising, as the two may co-exist.[Livingston, 2010; Anderst et al, 2013; Carpenter et al, 2013; Ward et al, 2013; Kemp et al, 2014] Back to top Trauma Trauma Trauma-related bruising may be caused by:Accidental injury (which may or may not be recalled by the person or their carer). Bruises from accidental trauma in children tend to be:Small (less than 15 mm in diameter).Oval to round in shape with non-distinct borders.Located above or near bony prominences on the front of the body (such as the forehead, knees, or shins).Non-accidental injury — see the section on Red flags suggesting non-accidental injury for more information. This may include:Child maltreatment.Domestic violence.Self-inflicted injury (commonly on the legs or areas within easy reach).Complementary therapies — such as cupping (where cups create local suction on the skin, to promote healing) or coining (where coin rubbing causes dermabrasion, to relieve symptoms such as myalgia and abdominal pain).[Livingston, 2010; Maguire and Mann, 2013; Ward et al, 2013] Back to top Vascular disorders Vascular disorders Senile purpuraA common and benign condition, resulting from impaired collagen production and capillary fragility in elderly people.Manifests as bruises which are usually bilateral on the extensor surfaces of the hands, forearms, face, and neck, which fade to a brownish colour over several months.Simple purpura ('easy bruising syndrome')A benign disorder typically occurring in otherwise healthy women, usually in their twenties or thirties.Manifests as bruising on exposed areas (such as the arms or legs) after minor trauma.May be associated with menorrhagia.Hereditary haemorrhagic telangiectasia (HHT)A rare autosomal dominant genetic disorder which leads to mucocutaneous telangiectasia of the skin, mucous membranes, and organs.There may be a positive family history, recurrent nosebleeds, fatigue, nail changes, and hair loss.Ehlers-Danlos syndromeThis causes joint hypermobility and skin translucency and hyperextensibility. It may present with gingival bleeding, prolonged bleeding after surgical procedures, and menorrhagia.Abnormalities in capillary structure and deficiencies of perivascular collagen cause vascular fragility, and blood vessels may rupture when subject to shearing forces.Has an estimated prevalence of 1 in 1000 people.Osteogenesis imperfectaThis is characterised by blue sclerae, short stature, bone fragility, dentinogenesis imperfecta, and adult hearing loss.Easy bruising after minimal or no trauma is thought to occur due to platelet dysfunction and capillary fragility.Has an estimated prevalence of 1 in 15,000–20,000 and is generally inherited as an autosomal dominant condition.Vitamin C deficiency (scurvy).May occur following a lack of fresh fruit and vegetables over prolonged periods of time.May present with perifollicular haemorrhage and bruising, dental deterioration, impaired wound healing, and coiled hairs.[Murtagh, 2007; Rydz and James, 2012; Carpenter et al, 2013; Ward et al, 2013; BMJ Best Practice, 2015; Patel and Butterfield, 2015] Back to top Platelet disorders Platelet disorders  Acute idiopathic thrombocytopenic purpura (ITP)Usually seen in children, caused by a reaction to a viral infection, resulting in the production of antibodies against platelets.Features include easy bruising, sudden onset of petechiae, nosebleeds, and menorrhagia. The person usually remains systemically well. Splenomegaly may be found on examination, however this is rare.Usually self-limiting, with about 90% of children completely recovering within 6 months. The remainder develop chronic ITP.Chronic ITPMost common in adult women.Rarely undergoes spontaneous remission.Henoch-Schlonlein purpura (HSP)This is a systemic vasculitis which can affect the skin, joints, bowels, and kidneys, and may follow an upper respiratory tract infection, usually in children.It typically causes reddish-purple purpura on the backs of the legs, buttocks, trunk, and back, and may be associated with joint pains and swelling, and gastrointestinal symptoms.Most cases spontaneously resolve within a few weeks.Aplastic anaemiaThis is a bone marrow disorder which commonly presents with fatigue, recurrent infections, and mucosal bleeding due to anaemia, leukopenia, and thrombocytopenia.Malignancy with bone marrow involvementAcute lymphocytic or myelogenous leukaemia often present with fatigue, recurrent infections, and mucosal bleeding or bruising. Full blood count may show a pancytopenia with thrombocytopenia, neutropenia, anaemia, and an elevated white blood cell count.Neuroblastoma in a child, where tumour infiltration of the bone may present with periorbital bruising. The child is likely to be systemically unwell and may have a palpable abdominal mass.Myeloma or myeloproliferative disorders may present with bone pain, fatigue, and anaemia.End-stage chronic kidney diseaseMay cause abnormalities of platelet aggregation and prolongation of bleeding time.Liver diseaseMay cause abnormalities of platelet function and number, the quality of clotting factors and proteins, and the quality of the skin and connective tissues.[George and Shattil, 1991; Murtagh, 2007; Rydz and James, 2012; Ward et al, 2013; BMJ Best Practice, 2015] Back to top Coagulation disorders Coagulation disorders Coagulation disorders are caused by a reduction or inhibition of circulating clotting factors, and may be inherited or acquired. Be aware that a negative family history does not exclude a genetically inherited disorder.Haemophilia A (factor VIII deficiency) and haemophilia B (factor IX deficiency)There are X-linked conditions, affecting 1 in 5000 males and 1 in 30,000 males respectively.The most severe forms occur almost exclusively in males.One third of cases arise secondary to new genetic mutations, where there will be no family history.Rarely female carriers can be affected, for example if there is consanguinity or Turner syndrome.Presents in 90% of people with severe disease by 1 year of age.Features depend on the level of clotting activity, and include spontaneous haemarthrosis, especially of the knees, ankles, and elbows; and muscle haematomas in severe haemophilia. Increased or delayed bleeding with injury or post-operatively is typical of milder disease.Liver diseaseMay be caused by drugs such as alcohol.Liver disease can cause impaired synthesis of clotting factors.Vitamin K deficiencyThis can result in functional deficiencies of factors II, VII, IX, and X, and proteins C and S, and can cause bleeding in an infant in the first weeks of life, when it is known as Haemorrhagic Disease of the Newborn (HDN).HDN is more prevalent in exclusively breastfed babies, and those with an inadequate or omitted dose of prophylactic vitamin K after birth.Bleeding can vary from bruising or petechiae in the first few days of life through to severe and life-threatening intracranial haemorrhage and/or gastrointestinal bleeding.Vitamin K deficiency can also occur due to malnutrition, and in older children and adults as a result of malabsorption, caused by conditions such as coeliac disease and cystic fibrosis.Von Willebrand disease (VWD)The most common inherited coagulation disorder, with an incidence of up to 1% in the general population.Inherited as an autosomal dominant disorder (equally common in males and females). A clear family history is not always evident as there may be incomplete penetrance and variable expression, and new mutations occur.Typically presents with mild to moderate mucocutaneous bleeding, such as nosebleeds, menorrhagia, or prolonged bleeding after surgical incisions or dental procedures. Women with VWD are five times more likely to have menorrhagia than those without the condition.It is usually a mild condition with an excellent prognosis.AmyloidosisThis condition may be associated with decreased factor X levels as amyloid light chain fibrils in the liver and spleen absorb this clotting factor.Bleeding symptoms may be exacerbated by vascular fragility.[Rashid et al, 1999; Chen et al, 2007; Djuric et al, 2007; Murtagh, 2007; Puckett and Offringa, 2000; Rydz and James, 2012; Carpenter et al, 2013; Ward et al, 2013; Neutze and Roque, 2016] Back to top Drugs Drugs Corticosteroids (endogenous, topical, or oral)Corticosteroids can alter dermal blood vessels and cause collagen degradation and skin atrophy. Subsequent trauma or shearing stress results in purpura, which may be minor and appear to occur spontaneously.Purpura typically occur on exposed areas of the hands and forearms, or on the legs; are common in older people; are dark purple, and do not show the sequential colour changes of a normal bruise; and may persist for several weeks.Drugs which cause platelet function inhibitionAspirin.Nonsteroidal anti-inflammatory drugs.Clopidogrel.Selective serotonin reuptake inhibitors (SSRIs).Drugs which cause low platelets (thrombocytopenia)Alcohol.Cephalosporins, nitrofurantoin, penicillins, sulfonamides.Carbamazepine and valproic acid.Quinine.Propranolol.Thiazide diuretics.Drugs which cause coagulation inhibitionWarfarin.Heparins.Apixaban, dabigatran, and rivaroxaban.[George and Shattil, 1991; Valente and Abramson, 2006; Murtagh, 2007; Neutze and Roque, 2016; BNF 70, 2015] Diagnosis Back to topDiagnosis of bruising causes Back to top How should I assess a person with bruising? How should I assess a person with bruising? Ask about symptoms which suggest an underlying platelet or coagulation disorder:Nosebleeds or gingival bleeding (mucocutaneous bleeding).Excessive or prolonged bleeding from haemorrhoids, other rectal bleeding, haematuria, or menorrhagia.Previous excessive bruising, or excessive or prolonged bleeding, that:Occurs soon after trauma (particularly if it is associated with a petechial rash or mucocutaneous bleeding) — suggests a platelet disorder.Is delayed, such as haemorrhage occurring 24 hours after a dental extraction (particularly if it is associated with bruises, haemarthrosis, or muscle haematomas) — suggests a coagulation disorder, such as haemophilia.Is new in onset, following previously normal responses to trauma — suggests an acquired problem.Ask about the person's general health to assess for underlying medical causes.A history of childhood chemotherapy or radiotherapy may result in a bone marrow disorder (such as myelodysplasia or leukaemia).Hypothyroidism may affect the quality of skin and subcutaneous tissue.Nutritional status — children who only eat a limited diet can develop nutritional deficiencies, leading to a coagulopathy, vascular fragility, and abnormal bruising.Tiredness, weight loss, fever, and night sweats may suggest malignancy.Joint pain, swelling, or reduced range of movement may suggest a haemarthrosis.Ask about alcohol use, and any prescribed or over-the-counter drugs.Ask whether there is a family history of:A known bleeding disorder (such as haemophilia, von Willebrand disease, or a platelet disorder).A tendency to bruise or bleed easily or spontaneously.Menorrhagia or postpartum bleeding in females, which may indicate a non-sex-linked disease (such as von Willebrand disease or factor XI deficiency).Consanguinity — have a lower threshold for suspecting an autosomal recessively inherited bleeding disorder, such as factor X deficiency.Hereditary haemorrhagic telangiectasia, Ehlers-Danlos syndrome, or osteogenesis imperfecta.For infants, children, the elderly, or people with learning difficulties, assess bruising in the context of the person's age, mobility and developmental status, and the explanation for injury (if any). For children, ask if:The child is crawling — bruising is uncommon in infants who are not yet mobile. See the section on Red flags suggesting non-accidental injury for more information.The child may have taken a drug (such as warfarin) accidentally.There is any history at birth of conditions suggesting an undiagnosed bleeding disorder, such as:Cephalhaematoma after instrumental delivery.Unexpected bleeding from the umbilical stump or delayed stump separation by up to 4 weeks, suggesting factor XIII deficiency.Haematoma after routine intramuscular vitamin K given at birth.Bleeding from the newborn heel prick test, suggesting factor XIII deficiency, or sometimes haemophilia.Assess the location and pattern of bruising, using pictorial or photographic records where possible and appropriate (for example in children):Distribution, number, site, shape, and measured size of bruises.Dependent areas — suggests thrombocytopenia or stasis factors.Atypical areas, such as on the trunk — suggests an underlying bleeding disorder, or non-accidental injury. See the section on Red flags suggesting non-accidental injury for more information.Patterned bruising, for example, the outline of a hand print or implement (such as a belt). See the section on Red flags suggesting non-accidental injury for more information.Only on the arms or legs — suggests trauma or changes in the skin or subcutaneous tissue.Periorbital — may suggest neuroblastoma in a child or amyloidosis (rare).Dorsum of the hands, extensor surface of the forearms, and the shins — suggests senile purpura.Note: the age of a bruise cannot be estimated accurately by its colour; if no bruises are currently present, ask the person to return when they reappear.Examine the skin, hair, and nails for:Age-related changes.Evidence of delayed healing, such as multiple scars or unhealed wounds — suggests corticosteroid use, hypothyroidism, ageing, self-inflicted injury, a collagen defect, or factor XIII deficiency.Laxity — may suggest Ehlers-Danlos syndrome.Pallor — suggests anaemia, which may be associated with malignancy.Jaundice — suggests liver disease.Petechiae (tiny, round, non-blanching, pinpoint flat spots less than 3 mm in diameter) — for example at clothing line pressure sites may indicate a platelet disorder; or if in the distribution of the superior vena cava they may follow coughing, vomiting, or strangulation.Palpable purpura (typically 3–10 mm in diameter) — suggests an underlying systemic vasculitis, such as Henoch-Schonlein purpura.Brittle hair and nails — suggests nutritional factors, ageing, hypothyroidism, or rarely hereditary haemorrhagic telangiectasia.Examine the joints for:Abnormalities suggestive of an inflammatory arthropathy (such as rheumatoid arthritis). See the CKS topic on Rheumatoid arthritis for more information.Hyperextensibility or elasticity — suggestive of Ehlers-Danlos syndrome.Swelling and tenderness — may indicate haemarthrosis, suggesting haemophilia.Tenderness — may be seen in acute leukaemia or neuroblastoma.Examine the abdomen for:Splenomegaly — suggests malignancy or idiopathic thrombocytopenic purpura (rare).Hepatomegaly — suggests malignancy or liver disease.Ascites, caput medusa, and spider telangiectasia — suggest chronic liver disease.Examine the head and neck.The oropharynx — for signs of bleeding, trauma, or healing injury to the frenulae (may suggest other non-accidental injury); gum hypertrophy may occur in monocytic leukaemia; wet purpura on the buccal mucosa or tongue is suggestive of severe thrombocytopenia.The eyes — use fundoscopy to check for retinal haemorrhages (may suggest other non-accidental injury).Examine for lymphadenopathy.Suggestive of leukaemia or amyloidosis. Back to top Red flags suggesting non-accidental injury Red flags suggesting non-accidental injury Suspect non-accidental injury and physical abuse when:Bruises are on a child who is not yet independently mobile (crawling, cruising, or walking).Bruising appropriate to learning to walk is common from around 1 year of age when most children have started 'cruising'. It is typically distributed on the anterior tibia and knee, followed by the upper legs and forehead.Bruises have indicative features.Disproportionate to the explanation of injury sustained.Unusually large.Present in multiple sites or in clusters.Of a similar shape and size.Patterned in the shape of a hand print, ligature, stick, tooth (or teeth marks), grip, or implement (such as a belt). Fingertip bruising is often found in children with a bleeding disorder.Associated with petechiae.Bruises are found in indicative places.Sites that are not typical for the age of the child.Any non-bony part of the body or face (including the eyes, ears, cheeks, back, abdomen, buttocks, arms, and genitalia).On both sides of the face or head.On the neck (consistent with strangulation).On the ankles and wrists (consistent with use of a ligature).The explanation for the bruising is implausible, inadequate, or inconsistent:With the child's presentation, normal activities, existing medical condition, age or developmental stage, or account — compared with that given by parents or carers.Between parents or carers.Between accounts over time.There is a delay in presentation.For more information on when to suspect or consider physical abuse in children, see the CKS topic on Child maltreatment - recognition and management.[Livingston, 2010; Anderst et al, 2013; Maguire and Mann, 2013; Ward et al, 2013; Kemp et al, 2014] Back to top Basis for recommendation Basis for recommendation The recommendations on how to assess a person with bruising are based on expert opinion in review articles [Maguire et al, 2005; Khair and Liesner, 2006; Valente and Abramson, 2006; McIntosh et al, 2007; Anderson and Thomas, 2010; Livingston, 2010; Anderst et al, 2013; Maguire and Mann, 2013; BMJ Best Practice, 2015; Neutze and Roque, 2016] and expert opinion in a textbook of general practice [Murtagh, 2007].Bruising in non-mobile infants is very rare [Livingston, 2010]. Less than 1% of babies younger than nine months of age show bruising, compared with 40–90% of children aged nine months of age and older [Ward et al, 2013].The recommendation not to estimate the age of a bruise from its colour is based on expert opinion in a systematic review [Maguire et al, 2005].Some authors suggest there is evidence that the presence of petechiae in association with bruising may indicate non-accidental injury [Maguire and Mann, 2013]. Back to top How should I investigate a person with bruising? How should I investigate a person with bruising? Arrange a urine dipstick test to check for non-visible haematuria which may suggest an underlying bleeding disorder or vasculitis.In adults with unexplained bruising, bleeding, petechiae, or hepatosplenomegaly consider arranging:A very urgent full blood count including platelet count (within 48 hours) and blood film.Clotting screen (prothrombin time [PT], activated partial thromboplastin time [aPTT], and international normalized ratio [INR] if the person is taking warfarin).Liver, renal, and thyroid function tests, depending on clinical judgement.In children and young people with unexplained bruising or bleeding offer:A very urgent full blood count including platelet count (within 48 hours) and blood film.Be aware that blood results such as full blood count and clotting screen can be normal in people with mild coagulation and platelet function disorders. Back to top Basis for recommendation Basis for recommendation Blood tests in adultsThe recommendation to consider arranging a very urgent full blood count in adults is to assess for leukaemia, and is based on the National Institute of Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2015].The recommendation to check a blood film is based on expert opinion in review articles that this can confirm whether there is true thrombocytopenia; and platelet and leukocyte morphology and characteristics can suggest haematological malignancies and hyperproliferative conditions [Rydz and James, 2012; Neutze and Roque, 2016]. Pancytopenia indicates bone marrow disease [BMJ Best Practice, 2015].The recommendation to consider checking clotting is based on expert opinion in review articles [Khair and Liesner, 2006; BMJ Best Practice, 2015; Neutze and Roque, 2016].The recommendation to consider checking liver and renal function tests for underlying causes of platelet abnormalities and dysfibrinogenaemia is based on expert opinion in review articles [Khair and Liesner, 2006; Rydz and James, 2012; Ward et al, 2013; BMJ Best Practice, 2015; Neutze and Roque, 2016]. Some authors suggest only checking liver function if clotting is deranged, and renal function if a bleeding disorder is suspected [Neutze and Roque, 2016].Impaired renal function in people taking anticoagulant drugs that require renal clearance, such as dabigatran, rivaroxaban, and apixaban, can cause excessive anticoagulation and subsequent bruising or bleeding [BMJ Best Practice, 2015].The recommendation on checking thyroid function tests is based on expert opinion in a review article [Rydz and James, 2012].Blood tests in childrenThe recommendation to offer a very urgent full blood count in children and young people is to assess for leukaemia, and is based on the National Institute of Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral  [NICE, 2015] and expert opinion in a review article [Ward et al, 2013].A blood film is helpful to confirm whether there is true thrombocytopenia; and platelet and leukocyte morphology and characteristics can suggest haematological malignancies or hyperproliferative conditions [Neutze and Roque, 2016]. Pancytopenia indicates bone marrow disease [BMJ Best Practice, 2015].Blood results can be normal in the presence of mild coagulation or platelet disordersThis recommendation is based on expert opinion in review articles [Khair and Liesner, 2006; Carpenter et al, 2013]. Back to top Differential diagnosis What else might it be? Skin conditions which might be mistaken for bruising include:Linear eruptionsAllergic contact dermatitis.  See the CKS topic on Dermatitis - contact for more information.Phytophotodermatitis — an inflammatory and pigmentary reaction of the skin to light, following contact with phototoxic substances from certain plants, such as giant hogweed.Stretch marks (striae).Non-linear eruptionsSlate-grey naevi (Mongolian blue spots) — macular blue-grey non-tender macules present at birth on the sacrum and buttocks in normal dark-skinned infants.Haemangiomas — benign congenital cutaneous tumours.Urticaria pigmentosa — numerous reddish-brown or pale maculopapules, plaques, or nodules which urticate within a few minutes of gentle rubbing. They are distributed symmetrically usually on the trunk and thighs, but can present anywhere on the body, sparing the face, palms, and soles. Dermatitis artefacta — self-inflicted skin lesions.Congenital vascular naevi.OtherSkin staining from dye or ink. Back to top Basis for recommendation Basis for recommendation Information on the differential diagnosis of bruising is based on expert opinion in review articles [AlJasser and Al-Khenaizan, 2008; Livingston, 2010; Ward et al, 2013; Patel and Butterfield, 2015] and expert opinion in two chapters of a dermatology textbook [Cox and Piette, 2010; Kennedy et al, 2010]. Management Back to topManagement Scenario: Management of bruising: covers when to consider admission or referral in children and adults, and when and how to manage in primary care. Back to top Scenario: Management Scenario: Management of bruising Back to top When should I admit or refer? When should I admit or refer a person with abnormal bruising? Admit the person if they have significant active bleeding and are not responding to simple measures (such as local compression).If non-accidental injury is suspected in children and young people, the elderly, or other vulnerable people:Refer immediately to the most appropriate agency — local child or adult social care services, the police, or the National Society for the Prevention of Cruelty to Children (NSPCC). If the person needs admission, ensure the hospital are aware of your concerns. For more information on the management of suspected child maltreatment, see the CKS topic on Child maltreatment - recognition and management.If non-accidental injury is not suspected:Refer children and young people for immediate specialist assessment for leukaemia if they have:Unexplained petechiae orHepatosplenomegaly orFull blood count results suggestive of leukaemia. For more information, see the CKS topic on Haematological cancers - recognition and referral.Refer children with periorbital bruising urgently (for an appointment within 48 hours) for specialist assessment for neuroblastoma if they have:A palpable abdominal mass orAn unexplained enlarged abdominal organ.For all other children, liaise with a paediatrician or paediatric haematologist to arrange venepuncture and further investigations as needed.Refer adults for immediate specialist assessment for leukaemia if they have:Full blood count results suggestive of leukaemia. For more information, see the CKS topic on Haematological cancers - recognition and referral.Refer all other adults to a haematologist for further investigations, the urgency depending on clinical judgement, if there is:A low platelet count.An abnormal clotting screen.Normal blood results in primary care but a bleeding disorder is still suspected. Back to top Basis for recommendation Basis for recommendation Admission criteriaThe recommendations on when to admit children and adults with active bleeding are pragmatic based on what CKS considers to be safe clinical practice.Referral criteria if non-accidental injury is suspectedThe recommendations on referral if non-accidental injury is suspected in children, the elderly, or other vulnerable people have been extrapolated from the National Institute for Health and Care Excellence (NICE) guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2009].Other referral criteria in childrenThe recommendations on when to refer children for suspected leukaemia or neuroblastoma are based on the NICE guideline Suspected cancer: recognition and referral [NICE, 2015].The recommendations on when to refer other children with abnormal bruising are based on expert opinion in review articles [Valente and Abramson, 2006; Anderson and Thomas, 2010; Livingston, 2010; Ward et al, 2013], and a textbook of general practice [Murtagh, 2007].Paediatric blood samples can be difficult to take, should not be traumatic, and should be analysed appropriately and without delay. Non-traumatic venepuncture is particularly important in a child with a bleeding disorder, in order to prevent further bruising or haematoma formation, and to prevent activation of coagulation in the blood samples [Anderson and Thomas, 2010].Other referral criteria in adultsThe recommendation on when to refer adults for suspected leukaemia is based on the NICE guideline Suspected cancer: recognition and referral [NICE, 2015].The recommendation on the referral of all other adults has been extrapolated from review articles which detail specialist haematology investigations that may be needed to determine any underlying cause of unexplained bruising or bleeding [Khair and Liesner, 2006; Rydz and James, 2012; BMJ Best Practice, 2015; Neutze and Roque, 2016].Specialist tests that may be arranged in secondary care include viral serology, serum autoantibodies, clotting factor assays, von Willebrand screen, and bone marrow aspirate or trephine. Back to top How should I manage bruising in primary care? How should I manage bruising in primary care? For simple bruising where there is no suspected underlying bleeding disorder:Prescribe simple analgesia such as paracetamol if required. See the CKS topic on Analgesia - mild-to-moderate pain for more information.For people taking warfarin with an abnormal clotting screen (a prolonged prothrombin time or increased international normalized ratio):If the person is monitored and managed in primary care, alter their warfarin dosage according to local protocols, or liaise with the local warfarin clinic or a haematologist, depending on clinical judgement. See the CKS topic on Anticoagulation - oral for more information.For people taking a drug that may cause thrombocytopenia, withdraw the drug where possible and appropriate, and monitor the person for resolution of symptoms and signs. Back to top Basis for recommendation Basis for recommendation The recommendation to prescribe simple analgesia if required for pain relief, and on the action to take if a person taking warfarin has abnormal bruising, is pragmatic based on what CKS considers to be good clinical practice.The recommendation to withdraw a potential drug cause of thrombocytopenia is based on expert opinion in a review article [BMJ Best Practice, 2015]. Supporting evidence Back to topSupporting evidence This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guidelines Suspected cancer: recognition and referral [NICE, 2015] and Child maltreatment: when to suspect maltreatment in under 18s  [NICE, 2009], together with expert opinion in review articles. The rationale for the assessment, referral, and primary care management of people with abnormal bruising is outlined in the relevant basis for recommendation sections of the topic. How this topic was developed Back to topHow this topic was developed This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website. Back to top Search strategy Search strategy Scope of searchA literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of bruising and purpura.Search datesNovember 2010 - March 2016Key search termsVarious combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.exp Contusions/, contusion$.tw., bruis$.tw., petechia$.tw., exp Ecchymosis/, ecchymos$.tw., exp Purpura/, purpura.tw.Sources of guidelines National Institute for Health and Care Excellence (NICE) Scottish Intercollegiate Guidelines Network (SIGN) Royal College of Physicians Royal College of General Practitioners Royal College of Nursing NICE Evidence Health Protection Agency World Health Organization National Guidelines Clearinghouse Guidelines International Network TRIP database GAIN NHS Scotland National Patient Pathways New Zealand Guidelines Group Agency for Healthcare Research and Quality Institute for Clinical Systems Improvement National Health and Medical Research Council (Australia) Royal Australian College of General Practitioners British Columbia Medical Association Canadian Medical Association Alberta Medical Association University of Michigan Medical School Michigan Quality Improvement Consortium Singapore Ministry of Health National Resource for Infection Control Patient UK Guideline links UK Ambulance Service Clinical Practice Guidelines RefHELP NHS Lothian Referral Guidelines Medline (with guideline filter) Driver and Vehicle Licensing Agency NHS Health at Work(occupational health practice)Sources of systematic reviews and meta-analyses The Cochrane Library: Systematic reviews Protocols Database of Abstracts of Reviews of Effects Medline (with systematic review filter) EMBASE (with systematic review filter)Sources of health technology assessments and economic appraisals NIHR Health Technology Assessment programme The Cochrane Library: NHS Economic Evaluations Health Technology Assessments Canadian Agency for Drugs and Technologies in Health International Network of Agencies for Health Technology AssessmentSources of randomized controlled trials The Cochrane Library: Central Register of Controlled Trials Medline (with randomized controlled trial filter) EMBASE (with randomized controlled trial filter)Sources of evidence based reviews and evidence summaries Bandolier Drug & amp; Therapeutics Bulletin TRIP database Central Services Agency COMPASS Therapeutic NotesSources of national policy Department of Health Health Management Information Consortium(HMIC)Patient experiences Healthtalkonline BMJ - Patient Journeys Patient.co.uk - Patient Support GroupsSources of medicines informationThe following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content. British National Formulary(BNF) electronic Medicines Compendium(eMC) European Medicines Agency(EMEA) LactMed Medicines and Healthcare products Regulatory Agency(MHRA) REPROTOX Scottish Medicines Consortium Stockley's Drug Interactions TERIS TOXBASE Micromedex UK Medicines Information Back to top Stakeholder engagement Stakeholder engagement Our policyThe external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:Clinical accuracy.Consistency with other providers of clinical knowledge for primary care.Accuracy of implementation of national guidance (in particular NICE guidelines).Usability.Principles of the consultation processThe process is inclusive and any individual may participate.To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.External reviewers are not paid for commenting on the draft topics.Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.All reviewers are invited to be acknowledged on the website.All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.StakeholdersKey stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.Stakeholders identified from the following groups are invited to review draft topics:Experts in the topic area.Professional organizations and societies(for example, Royal Colleges).Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer's Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.Guideline development groups where the topic is an implementation of a guideline.The British National Formulary team.The editorial team that develop MeReC Publications.Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.Patient engagementClarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:Topic selectionScoping of topicSelection of clinical scenariosFirst draft internal reviewSecond draft internal reviewExternal reviewFinal draft and pre-publicationOur lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals. Back to top Evidence exclusion criteria Evidence exclusion criteria Our policyScoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.Standard exclusions for scoping literature:Animal studiesOriginal research is not written in EnglishPossible exclusions for reviewed literature:Sample size too small or study underpoweredBias evident or promotional literaturePopulation not relevantIntervention/treatment not relevantOutcomes not relevantOutcomes have no clear evidence of clinical effectivenessSetting not relevantNot relevant to UKIncorrect study typeReview articleDuplicate reference Back to top Organizational, behavioural and financial barriers Organizational, behavioural and financial barriers Our policyThe CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.FeasibilityStudies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.Organizational and Financial Impact AnalysisStudies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.Eligible populationCurrent interventionsLikely uptake of new intervention or recommendationCost of the current or new intervention mixImpact on other costsCondition-related costsIn-direct costs and service impactsTime dependenciesCost-effectiveness or cost-benefit analysis studies are identified where available. We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation. Back to top Declarations of interest Declarations of interest Our policyClarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:Personal financial interestsPersonal family interestPersonal non-financial interestNon-personal financial gain or benefitAlthough particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons.An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.Who should declare competing interests?Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.Competing interests declared for this topic:None. References Back to topReferences AlJasser,M. and Al-Khenaizan,S. (2008) Cutaneous mimickers of child abuse: a primer for pediatricians. European Journal of Pediatrics. 167(11), 1221-1230. [Abstract] Anderson,J.A.M. and Thomas,A.E. (2010) Investigating easy bruising in a child. BMJ. 341, c4565. Anderst, J.D., Carpenter, S.L. and Abshire, T.C. et al (2013) Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 131(4), e1314-e1322. [Abstract] BMJ (2015) Assessment of easy bruising. British Medical Journal.. www.bestpractice.bmj.com/ [Free Full-text] BNF 70 (2015) British National Formulary.70th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain. Carpenter, S.L., Abshire, T.C. and Anderst, J.D. et al (2013) Evaluating for suspected child abuse: conditions that predispose to bleeding. Pediatrics. 131(4), e1357-e1373. [Abstract] Chen,C.S., Cumbler,E.U. and Triebling,A.T. (2007) Coagulopathy due to celiac disease presenting as intramuscular hemorrhage. Journal of General Internal Medicine. 22(11), 1608-1612. [Abstract] Cox, N.H. and Piette, W.W. (2010) Rook's textbook of dermatology. In: Burns, T., Breathnach, S., Griffiths, C., and Cox, N. (Eds.) Purpura and microvascular occlusion.3 edn.Chichester: Wiley-Blackwell., 49.1-49.51. Djuric,Z., Zivic,S. and Katic,V. (2007) Celiac disease with diffuse cutaneous vitamin K-deficiency bleeding. Advances in Therapy. 24(6), 1286-1289. [Abstract] George,J.N. and Shattil,S.J. (1991) The clinical importance of acquired abnormalities of platelet function. New England Journal of Medicine. 324(1), 27-39. Kemp, A.M., Maguire, S.A. and Nuttall, D. et al (2014) Bruising in children who are assessed for suspected physical abuse. Archives of disease in childhood. 99(2), 108-113. Kennedy,C.T.C., Burd,D.A.R. and Creamer,D. (2010) Rook's textbook of dermatology. In: Burns,T., Breathnach,S., Cox,N., Griffiths,C. (Eds.) Mechanical and thermal injury.Chichester: Wiley-Blackwell., 28.1-28.94. Khair,K. and Liesner,R. (2006) Bruising and bleeding in infants and children--a practical approach. British Journal of Haematology. 133(3), 221-231. [Abstract] Livingston, N. (2010) Bruising in infancy: when is it an emergency?. Pediatric annals. 39(10), 646-654. [Abstract] Maguire, S. and Mann, M. (2013) Systematic reviews of bruising in relation to child abuse - what we have learnt: an overview of review updates. Evidence-based child health. 8(2), 255-263. [Abstract] Maguire,S., Mann,M.K., Sibert,J. and Kemp,A. (2005) Can you age bruises accurately in children? A systematic review. Archives of Disease in Childhood. 90(2), 187-189. [Abstract] Mauer, A.C., Khazanov, N.A., Levenkova, N., et al. (2011) Impact of sex, age, race, ethnicity and aspirin use on bleeding symptoms in healthy adults. Journal of Thrombosis and Haemostasis. 9(1), 100-108. McIntosh,N., Mok,J.Y. and Margerison,A. (2007) Epidemiology of oronasal hemorrhage in the first 2 years of life: implications for child protection. Pediatrics. 120(5), 1074-1048. [Abstract] Murtagh,J. (2007) John Murtagh's general practice.4th edn. New South Wales: McGraw-Hill Australia Pty Ltd. Neutze, D. and Roque, J. (2016) Clinical evaluation of bleeding and bruising in primary care. American family physician. 93(4), 279-286. [Abstract] NICE (2009) When to suspect child maltreatment (NICE guideline). National Institute for Health and Clinical Excellence.. www.nice.org.uk [Free Full-text] NICE (2015) Suspected cancer: recognition and referral (NG12). National Institute for Health and Care Excellence.. www.nice.org.uk [Free Full-text] Patel, B. and Butterfield, R. (2015) Common skin and bleeding disorders that can potentially masquerade as child abuse. American journal of medical genetics part C (seminars in medical genetics). 169(4), 328-336. [Abstract] Puckett,R.M. and Offringa,M. (2000) Prophylactic vitamin K for vitamin K deficiency bleeding in neonates (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text] Rashid,M., Durie,P., Andrew,M., et al. (1999) Prevalence of vitamin K deficiency in cystic fibrosis. American Journal of Clinical Nutrition. 70(3), 378-382. [Abstract] Rydz, N. and James, P.D. (2012) Why is my patient bleeding or bruising?. Haematology/oncology clinics of north America. 26(2), 321-344. Valente,M.J. and Abramson,N. (2006) Easy bruisability. Southern Medical Journal. 99(4), 366-370. [Abstract] Ward, M.G.K, Ornstein, A. and Niec, A. et al (2013) The medical assessment of bruising in suspected child maltreatment cases: a clinical perspective. Paediatrics and child health. 18(8), 433-442. [Abstract]