Related Terms

• Bleeding disorders, broken blood vessels, bump, compartment syndrome, contusion, ecchymosis, injured blood vessels, myositis ossificans, pain, petechiae, skin discoloration, swelling.

Background

• A bruise, medically referred to as a contusion, is caused when tiny blood vessels are damaged or broken as the result of a blow to the skin. The raised area of a bump or bruise results from blood leaking from injured blood vessels into the tissues, such as muscle, as well as from the body's response to the injury. A purplish, flat bruise that occurs when blood leaks out into the top layers of skin is called an ecchymosis. Petechiae, another type of bruise, refers to very small, one to three millimeter accumulations of blood beneath the skin.

• Bruises change colors over time in a predictable pattern, so that it is possible to estimate when an injury occurred by the color of the bruise. Initially, a bruise will be reddish, the color of the blood under the skin. Individuals with darker skin tones may have trouble distinguishing a bruise. After one to two days, the red blood cells begin to break down, and the bruise will darken to a blue or purplish color. This fades to green at about day six. Around the eighth or ninth day, the skin over the bruised area will have a brown or yellowish appearance, and the skin will gradually change back to its normal color.

• Bruising can occur due to trauma or injury, certain medications that thin the blood (including warfarin or Coumadin® and aspirin), physical abuse, bleeding disorders (such as hemophilia), and other medical conditions, including immune disorders (such as human immunodeficiency virus (HIV)), leukemia (cancer of the blood), drug and alcohol addiction, and aplastic anemia (lack of red blood cell production).

• The injury required to produce a bruise varies with age. While it may take quite a bit of force to cause a bruise in a young child, even minor bumps and scrapes may cause extensive bruising or ecchymosis in an elderly person. Blood vessels become more fragile as individuals age and bruising may even occur without prior injury in the elderly.

Causes and Risk Factors

• Anyone can get a bruise. Some individuals, including women, are more prone to bruising than are others. Easy bruising in women is thought to be due to hormonal changes. As an individual gets older, several factors may contribute to increased bruising, including aging capillaries and thinning skin. Over time, the tissues supporting these vessels weaken, and capillary walls become more fragile and prone to rupture. During the aging process, the skin becomes thinner and loses some of the protective fatty layer that helps cushion blood vessels against injury. Excessive exposure to the sun can thin the skin much like aging, as does smoking and lack of hydration (water).

• Medications: The amount of bruising may also be affected by medications that interfere with blood clotting. Thus, medications may cause more bleeding into the skin or tissues. Certain drugs, medications, substances, and toxins may cause bruising. It is recommended by healthcare professionals to always advise a doctor and/or pharmacist of any medications or treatments being used, including prescription, over-the-counter (OTC), and integrative therapies (including herbs and vitamins). Medications that may cause an increase in bleeding include: blood thinning medications, such as warfarin (Coumadin®), clopedigrel (Plavix®), and aspirin; birth control pills, such as estrogen and progesterone combinations; non-steroidal anti-inflammatory drugs, such as ibuprofen (Advil®), naproxen (Naprosyn®, Aleve®), celecoxib (Celebrex®), and indomethacin (Indocin®); some diuretics (drugs that increase fluid loss), such as furosemide (Lasix®); and corticosteroids or steroids, such as prednisone (Deltasone®).

• Certain dietary supplements such as vitamin E, fish oil, ginkgo (Ginkgo biloba), ginger (Zingiber officinalis), and garlic (Allium sativum) also may increase the risk of bruising. These and many other supplements may have a blood-thinning effect. It is highly recommended by healthcare professionals to tell a pharmacist or doctor when taking dietary supplements along with prescription medications, such as those that may thin the blood.

• Other causes: The following are some of the possible causes of bruising as a symptom: sports-related injuries; accidents; falls; physical abuse; bleeding disorders, such as hemophilia and Von Willebrand's disease; Ehlers-Danlos syndrome, which is a genetic defect in collagen and connective-tissue synthesis and structure; immune disorders, such as human immunodeficiency virus (HIV); leukemia (cancer of the blood); liver diseases, such as cirrhosis; drug and alcohol addiction; aplastic anemia (lack of red blood cell production); disseminated intravascular coagulation (DIC, or blood coagulation throughout the body); and scurvy (a condition caused by a lack of vitamin C).

Signs and Symptoms

• The main symptoms of bruising are pain, swelling, and skin discoloration. The bruise begins as a pinkish red color that may be very tender to touch. A bruised muscle is often difficult to use. For example, patients may exhibit difficulty walking with a thigh muscle bruise.

• Eventually, the bruise changes to a bluish color, then greenish-yellow, and finally returns to the normal skin color as it heals.

• Generally, with impacts to the body, the harder force of the impact, the larger the bruise. However, if an individual bruises easily, a minor bump can result in substantial discoloration. Arms and legs are typical locations for bruises.

• Bruising may also indicate something more serious, such as a blood-clotting problem, a blood disease, major trauma or injury, or physical abuse. It is recommended by healthcare professionals to see a doctor if: the individual has unusually large or painful bruises, particularly if bruises seem to develop for no known reason; the individual is bruising easily and experiencing abnormal bleeding elsewhere, such as from the nose, gums, or intestinal tract; or the individual has no history of bruising but suddenly experience bruises, particularly if they recently started a new medication.

• These signs and symptoms can indicate that the individual has low levels or abnormal function of platelets. Platelets are components of blood that help it clot after an injury.

• Bruising that occurs around the navel may indicate dangerous internal bleeding; bruising behind the ear, called Battle's sign, may be due to a skull fracture; and raised bruises may point to autoimmune disease such as systemic lupus erythematosus (lupus).

Complications

• Occasionally, the area of a bruise will become firm and may actually start increasing in size instead of going away. The bruise may also continue to be painful. There are two major causes for a bruise that gets worse. First, if a large collection of blood is formed under the skin or in the muscle, the body may wall the blood off causing what is called a hematoma. A hematoma is nothing more than a small pool of blood. Hematomas may need to be drained by a healthcare professional.

• Getting prompt medical treatment and following a doctor's advice about rehabilitation can help an individual avoid serious medical complications that occasionally result from deep muscle contusions and bruises. These complications include compartment syndrome and myotosis ossificans.

• Compartment syndrome: In certain cases, rapid bleeding may cause extremely painful swelling within the muscle group of the arm, leg, foot, or buttock. The build-up of pressure from fluids several hours after a contusion injury can disrupt blood flow and prevent nourishment from reaching the muscle group underneath the bruise. Compartment syndrome may require urgent surgery to drain the excess fluids.

• Myositis ossificans: Myositis ossificans is a condition in which the bruised muscle grows bone instead of new muscle cells. Young athletes who try to rehabilitate a severe contusion too quickly sometimes develop this condition. Symptoms may include mild to severe pain that does not go away and swelling at the injury site. Abnormal bone formations can also reduce flexibility. Vigorous stretching exercises may make the condition worse. Rest, ice, compression, and elevation to reduce inflammation will usually help. Gentle stretching exercises may be used to improve flexibility. Surgery is rarely required.

Diagnosis

• Bruising is usually a minor problem, which does not require a medical diagnosis. However, when extensive bruising, bruising with no apparent cause, or bruising in certain locations (such as around the ears or the navel) is present, a doctor will evaluate the individual's health using blood tests, such as blood clotting and platelet counts. If the area of the bruise becomes hard, an x-ray may be required.

Treatment

• Once a bruise has formed, not much can be done to treat it. Most eventually disappear as the body reabsorbs the blood.

• It is often recommended that ice packs be applied on and off during the first 24 hours of injury to reduce the bruising. After that, heat, especially moist heat, is recommended to increase the circulation and the healing of the injured tissues. Rest, elevation of the effected part, and compression with a bandage will also retard the accumulation of blood. Long periods of standing may cause the blood that collects in a bruise to seep through the tissues. Rarely, if a bruise is so large that the body cannot completely absorb it or if the site becomes infected, it may have to be surgically removed.

• If the bruise is being caused by medication interactions or dietary supplement/medication interactions, the individual and their doctor will stop the substance causing the increase in bleeding. If there are any questions about whether or not a medication can contribute to bruising, asking a doctor or pharmacist is important. Stopping medications should only be done under the supervision of a doctor.

• Minor bruises are easily treated, but it is recommended by healthcare professionals to contact a doctor if: a bruise doesn't go away after two weeks; bruising occurs often without bumping into things and bruises seem to develop for no known reasons; a bruise is getting more painful; the bruise is swelling; the individual cannot move a joint; or the bruise is near the eye.

• Bruises accompanied by persistent pain or headache also may indicate a more serious underlying illness and require medical attention. It is recommended by healthcare professionals that individuals: do not attempt to drain the bruise with a needle; do not continue running, playing, or otherwise using the painful, bruised part of the body; and do not ignore the pain or swelling.

• If the bruise is caused by domestic violence, appropriate counseling is needed. Doctors will help the individual find a social worker or other healthcare counselor to help with domestic violence issues. Battered women's shelters are available for those in need. The National Domestic Abuse Hotline can be reached at 1-800-799-SAFE (7233) or 1-800-787-3224. For children, the National Child Abuse Hotline can be reached at 1-800-4-A-CHILD.

Integrative Therapies

• Unclear or conflicting scientific evidence:

• Arnica: Arnica (Arnica montana) is commonly used in herbal ointments and oils applied on the skin as an anti-inflammatory and pain-relieving agent for aches, bruises, and sprains on unbroken skin. Homeopathic and topical (on the skin) arnica is widely used to prevent or treat hemorrhages (heavy bleeding), hematomas (blood clots), and bruising. More study is needed in this area to draw a firm conclusion.

• Avoid if allergic or hypersensitive to arnica or any member of the Asteraceae or Compositae families (sunflowers, marigolds or any related plants like daisies, ragweed or asters). Use cautiously with blood thinners, protein-bound drugs, cholesterol or heart medications, or diabetes drugs. Use cautiously with a history of stroke. Avoid contact with open wounds or near the eyes and mouth. Avoid if pregnant or breastfeeding.

• Traditional or theoretical uses lacking sufficient evidence:

• Comfrey: Comfrey (Symphytum spp.) has been used traditionally for bruises, and external and internal wounds. Its traditional name, bruisewort, is derived from its suggested ability to reduce swelling and bruising. Topical comfrey containing creams have been used in clinical study for bruises, sprains, and distortions and painful conditions of muscles and joints. Although there is good scientific evidence supporting the use of comfrey for inflammation, scientific data on the specific effects of comfrey for bruises is lacking. High quality clinical research is needed in this area for a conclusion to be made.

• Avoid if allergic/hypersensitive to comfrey, its constituents, or members of the Boraginaceae family. Avoid oral comfrey; oral use has caused death. Avoid topical comfrey on broken skin, or in individuals with or at risk for hepatic disorders, cancer, or immune disorders. Use topical creams containing comfrey cautiously if taking anti-inflammatory medications or cytochrome P450 3A4-inducing agents. Use extreme caution when using topical creams containing comfrey for extended periods. Avoid if pregnant or breastfeeding.

Prevention

• To prevent minor bruising, healthcare professionals recommend eliminating household clutter that could cause bumps or falls. Long-sleeved shirts and pants may provide an extra layer of protection for the skin. Avoiding prolonged exposure to the sun to help avoid its aging effects and the increased bruising risk that may result is also recommended by healthcare professionals. Wear sunscreen when exposed to the sun for extended lengths of time.

• If the sight of a bruise is cosmetically bothersome, the individual can cover the bruise with makeup until it has healed.

• Vitamin K promotes normal clotting in the blood, and therefore may help reduce the tendency to bruise easily. Green leafy vegetables, alfalfa, broccoli, seaweed, and fish liver oils are dietary sources of vitamin K and may help prevent bruising. Other foods to eat would be those containing bioflavonoids (antioxidants), such as berries (blueberries, blackberries, strawberries, raspberries) and citrus fruits. These foods can assist in strengthening the connective tissue, which will decrease the spread of blood and bruising.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. American Academy of Family Physicians. http://familydoctor.org.

2. Centers for Disease Control and Prevention. www.cdc.gov.

3. Davey AL, Foxton SJ, Bala P, et al. Bruising: when it is spontaneous and not idiopathic thrombocytopenia purpura. J Paediatr Child Health. 2007;43(4):310-1. View Abstract

4. Khair K, Liesner R. Bruising and bleeding in infants and children--a practical approach. Br J Haematol. 2006;133(3):221-31. View Abstract

5. National Institute on Aging. www.nia.nih.gov.

6. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

7. Payne G, Langlois N, Lennard C, et al. Applying visible hyperspectral (chemical) imaging to estimate the age of bruises. Med Sci Law. 2007;47(3):225-32. View Abstract

8. Punwar S, Hall-Craggs M, Haddad FS. Bone bruises: definition, classification and significance. Br J Hosp Med (Lond). 2007;68(3):148-51. View Abstract

9. Valente MJ, Abramson N. Easy bruisability. South Med J. 2006;99(4):366-70. View Abstract