Q. Hello Dr. Costrini. My name is Miriam and I am a long-time Savannah resident, although I am not from here originally. I am 66 years of age and have been in reasonably good health. I have mild high blood pressure, the usual aches and pains of arthritis, and visit my family physician and gynecologist on a regular basis. Over the past several years I have experienced very easy bruising of my skin. With even mild bumping against a table I will develop a purple mark that will last for weeks and they are now becoming more frequent. They are certainly unsightly, give the impression that I have been beaten, and have me worried regarding their cause. My doctors have looked at some of the bruises and simply shrug their shoulders and tell me it is nothing serious. I am getting uncomfortable and would like to have the problem go away. What do you think?

A. Your question and concerns are common in the practice of medicine. I must tell you that indeed the answer you have gotten is probably a typical answer. It is indeed generally unsatisfactory for most patients as it is for you. Doctors have learned more about bruising over the past several years and we should be able to give you a better answer. First, a bruise is actually a collection of blood just below the skin that results in the purple discoloration that you notice. The skin and the tissues just below the skin normally serve as protectors of small blood vessels in the region. Damage that causes the flow of blood, usually in small amounts, can be quite minor. Normally when mild trauma occurs, such as when inadvertently bumping up against a piece of furniture, circulating blood components called platelets serve as a short term bandages to close tiny holes in the blood vessels. Following this, coagulation proteins in the blood help tighten the plug and provide for permanent closure of the vessel and prevention of bleeding. When a doctor sees a large bruise he considers the role of the skin, the subcutaneous tissues, the blood vessels themselves, the platelet number and function, and the coagulation proteins since they all participate in prevention of that bruise that you so readily see.

In the majority of cases bruising is associated with three principal causes. First is unrecognized trauma. This is particularly important in young children and in older adults patients who may present with multiple bruises. Unfortunately, we do have to consider the possibility of abusive actions against very young or elderly, infirm patients. The second cause is age and the third relates to medication-induced effects on the skin, blood vessels, and platelet function. With age the skin and subcutaneous tissues become thinner and in fact the ability of these barriers to protect the underlying blood vessels is reduced. Minimal trauma that in years past would not cause bruising, will indeed do so in the older age patients because of loss of the protective effects of the skin and underlying tissues. Medications are a particularly common cause of bruising. Certainly we all would recognize that anticoagulants such as Coumadin will cause bruising by blocking the coagulation proteins. Aspirin and the drug Plavix certainly have an effect on platelet function and they prevent the aggregation of platelets at the site of a tiny break in the blood vessels following minimal trauma. Hence, the bruise will occur. Patients however may be taking aspirin, Goody powders, Bufferin compound, etc. for a variety of aches and pains not recognizing that these medications may be the cause of the secondarily recognized bruising problem. Similar bruising may occur with nonsteroidal antiinflammatory drugs such as ibuprofen and Celebrex. Similarly corticosteroids i.e.Prednisone, can have an effect on the skin and subcutaneous tissues and markedly worsen platelet function. One of the commonest problems is over-the-counter medications particularly the herbal drugs such as ginger, ginkgo, vitamin C, vitamin E, and garlic. These agents can adversely interact with other drugs and cause marked bruising of the skin. In addition to Coumadin used in heart disease, the other heart drug quinidine certainly can affect the ability of the blood to clot and lead to easy bruising. Some blood pressure medications may do the same. Another cause of bruising are the inherited disorders. These can be disorders such as hemophilia, von Willebrands disease, and others may be defined by a family history.

You mention that your doctors did not pursue your complaint very vigorously. I suspect that you are otherwise doing well and that you were perceived as a healthy individual with some fragile blood vessels. This in fact is the most common problem and medications as listed above may play a role. In addition, blood testing is not particularly helpful for determining the cause of bruising. A low platelet count may be seem at times. The history is very much more important. Tests for more serious problems such as kidney disease, liver disease, or other blood abnormalities would come to mind during a physical examination and would suggest a specialty referral. In general therefore, your easy bruising probably does not reflect a serious disorder, may indeed reflect the use of common medications, or some of the prescription medications you are taking for arthritis or for your blood pressure, or some of the over-the-counter herbal medications you may be taking to generally support your health. If you recall from family history other members with bleeding disorders then it may be indeed worth pursuing some of the less common inherited disorders of coagulation. Finally, the role of age is always a sensitive one. But, if you have noted in conjunction with the bruising some thinning of the skin, some slow but real weight loss over the past several years, and some general weakness which may cause some uncertainty in your gait leading to a bit more trauma against furniture etc., then indeed age may be participating in some of the inadvertent trauma associated with age. However, in your situation that does not appear to be the case and I would be suspicious particularly regarding the medicine cabinet. I hope this information is helpful. You may wish to discuss these possibilities with your physician . ncostrini@GeorgiaGi.com >