Bleeding Into the Skin: Causes & Diagnosis

Bleeding beneath the Skin:

Bleeding beneath the skin, also known as ‘Haemorrhaging’, is a condition where the blood vessels tear or rupture, causing the blood to leak and collect by forming lumps in the nearby tissues or spaces under the skin. This leads to skin discoloration, resulting into red, blue, black or purple skin patches. The resultant size and appearance of skin patches, is determined by the number and type of ruptured blood vessels. Breakage of few capillaries or blood vessels, resulting into blood spots lesser than 2mm in width size is termed as ‘Petechiae’.

While, reddish-purple blood spots caused due to the breakage of few more capillaries with a width size between 2mm to 1cm are termed as ‘Purpura’. Capillary breakage in large numbers causing bluish to purple/blackish blood spots in varying sizes is termed as ‘Ecchymosis’. Fresh bruises tend to be red in colour and transform into dark black to bluish spots after couple of hours. The healing time of these skin bruises tend to vary from few days to several weeks, depending upon their severity.

Causes of Bleeding underneath the skin:

• Injury/Trauma due to exerted pressure/force on certain body parts causes the blood from damaged/ruptured blood vessels to accumulate beneath the skin.
• Exercising/playing contact sports that involve repeated hitting, friction and brutal proximity with the sport opponent and the equipment can caused ‘Sport Purpura’.
• Inappropriately fitted clothes, spectacles, shoes, carrying heavy bags that cause friction against the skin can lead to internal bleeding/petechiae’s.
• Sunburns (Solar purpura) caused due to the ultra-violet rays of the sun stimulates the cutaneous veins and capillaries causing them to dilate and eventually to rupture, resulting in internal bleeding and patchy skin.
• Reaction to certain allergens (Henoch-Schönlein Purpura) is caused due to impaired immune system, when the body produces Immunoglobulin (IgA), an antibody that fights with the infections. Thus, causing the IgA to accumulate in the blood vessels and making them inflamed, that can lead to internal bleeding.
• Process of birth, due to the excess pressure while passing through the birth canal can cause internal bleeding (petechiae’s) in the infants. And the resultant strain of the birth on the blood vessels can also result into internal bleeding in mothers.
• Use of certain medical equipment’s such as casts, braces or crutches can cause strain on the blood vessels, causing them to bleed internally.
• Phenomenon of aging makes the dermal tissues thinner resulting in fragile blood vessels. Therefore, even negligible trauma and exposure to sun, can cause the outer blood vessels to rupture and bleed into the surrounding skin resulting in Ecchymosis (dark purple patches), also termed as, Senile Purpura/Actinic Purpura/Bateman Purpura.
• Coughing, vomiting or crying that puts strain on the blood vessels, can cause them to tear/rupture resulting into internal bleeding.
• Laborious job/work that involves strenuous work activities like lifting heavy objects etc can cause strain on the blood vessels, causing them to rupture and bleed underneath the skin.
• Chemotherapy/Radiation process damages the bone marrow. Platelets enable to stop bleeding by making the blood clot. As these treatments cause damage to the bone marrow, it results into low platelet count.

This condition is termed as ‘Thrombocytopenia’. As the platelet volume gets reduced, chances of bruises and internal bleeding increases, developing into rashes or small red patches/petechiae’s.

Leukaemia

It is a cancer that impairs the development and functioning of WBC’s (White Blood Cells) causing them to reduce. Unlike the normal cells, the impaired cells do not die and spread into the blood by overcrowding the normal cells.

As the impaired cells continue to multiply, making the Leukaemia severe, the production of platelets gets disrupted. Thus, enough platelets are not available to block the ruptured capillaries causing the blood to leak into the skin. This leads to emergence of red, purple or brown patches/petechiae’s.

Consumption of alcohol/tobacco-based products/drugs can cause irritation to the internal organs or the lining of the stomach, that can result into internal bleeding. Deficiency of certain vitamins (such as Vitamin A, C, K, B12/Folic acid) can cause the skin to become inflamed and the blood vessels/capillaries to burst. This can cause bleeding into the skin (small red spots/petechiae’s). Because certain vitamins are essential for skin repair and curing inflammations. Strep Throat is a bacterial infection of the throat that causes inflammation of the tonsils. This can cause the capillaries/blood vessels to burst and leak blood causing small red spots on the mouth roof termed as ‘Palatal Petechiae’. Liver damage can cause scarring (liver cirrhosis) leading to itchy skin and easy bruising. Also, renal (kidney) damage or failure can result into internal bleeding. Rocky Mountain Spotted fever, is bacterial infection caused by tick bites, developing into tiny bleeding spots, starting from the wrist and hands. Cytomegalovirus is a viral infection that can cause reddish spots on the skin surface. Viral Haemorrhagic fever (such as Dengue, Ebola, Marburg, Yellow fever, Lassa) are caused upon contact with the infected animals, insects or people carrying the virus.

It results into damage to the blood vessels, causing them to leak, by affecting the clotting ability. This causes internal bleeding and skin spotting.

Sepsis

It is a life-threatening condition caused when the immune system of the body releases chemical that results into reverse condition by developing inflammation throughout the body. One of the symptomatic factors caused discoloured patches termed as Purpura fulminans.

Systemic lupus Erythematosus (SLE) is a chronic condition causing inflamed connective tissues (such as the blood vessel linings and cartilage) that offer strength and flexibility to body parts.

It is an auto-immune disorder, wherein the immune system of the body becomes hyper-active attacking the healthy tissues. The reduced no of normal cell fragments/platelets that help in clotting, cause bleeding beneath the skin (petechiae’s).

Disseminated Intravascular Coagulation (DIC) is a serious condition which results into rapid blood clotting, causing less flow of blood or prevented blood flow to the organs. As DIC gets more severe, platelets that are clotting elements get used up. As a result, it causes bleeding and red spots on the skin surface/petechiae’s.

Thrombotic Thrombocytopenic Purpura (TTP) is a rare condition that affects the clotting tendency, resulting into small clots throughout the body. The tiny clots prevent the blood from reaching the vital organs, thus hampering the functional effectivity.

The forming of small clots consumes several blood platelets. Thus, enough platelets do not remain while the body requires them. And small purplish bruises appear on the skin surface that are symptomatic of the condition.

Haemolytic Uremic Syndrome (HUS) causes damage to the platelets that are responsible for clotting, which has an adverse effect on the blood and blood vessels (red blood cells and platelets). It also results into anaemia, kidney failure, unexplained bleeding and bruising or spotting on the skin surface.

Vasculitis is a condition that affects the small and medium vessels of the skin and not the intrinsic organs, resulting in symptomatic skin conditions such as Petechiae’s or Palpable Purpura.

Meningitis is an infectious condition that causes inflammation of the Meninges, the membranous layer of the spinal cord and the brain. It is caused by the bacterium called ‘Meningococcus’, which results in bleeding beneath the skin.

Scarlet fever is caused due to the streptococcus bacteria. Scarlet spots or red skin patches develop, the condition gets severe due to capillary rupture.

Infective Endocarditis is an infection of the endocardium, which can cause Conjunctival Petechiae.

Marfan Syndrome is a genetic/inherent condition that affects the connective tissue, that offers strength and firmness to the cells of the body. It affects the bones, eyes, nervous system, skin, lungs, heart and the blood vessels.

In this condition as the walls of the Aorta get weak, that can cause swelling, leading to rupture and internal bleeding in severe cases.

Ehlers-Danlos Syndrome

It is an inherent condition that causes weakened connective tissues. It affects the joints, skin and walls of the blood vessels. It causes the skin to bruise easily and in serious conditions, can lead to dilation and bursting of blood vessels.

Von Willebrand’s

It is a genetic deficiency of von Willerbrand factor, that causes ‘dysfunctional platelets’, which enable clotting. It leads to difficulty in blood clotting and cause easy bruising, excess bleeding or lumping underneath the skin.

Other medicines/drugs that can cause internal bleeding/hemorrhaging are

• NSAID’s (Non-steroidal anti-inflammatory Drug’s) such as Diclofenac, Ibuprofen that are prescribed for pain reduction and inflammation, can irritate and erode the lining of the stomach leading to internal bleeding.
• Anti-coagulators and blood-thinning medicines (such as Aspirin, Clopidogrel, Apixaban, Rivaroxaban, Heparin and Warfarin) cause thinning of the blood, preventing blood cells from sticking together and clotting.
• Topical cortico-steroids are anti-inflammatory drugs, and one of the probable side-effects include thinning of the skin and easy bruising.

Diagnosis

• A physical examination of the patient is carried out to identify the causes of bleeding into the skin.
• The medical records of the patient are reviewed by the doctor through interrogation about
• The potential reasons that could have caused bruising/skin blotches
• All the related/unrelated symptoms
• Any medications/drugs/NSAID’s patient has been consuming
• Any previous surgeries/injuries
• Medical records of the family
• Use of any natural/herbal nutritional supplements

Tests

Complete Blood Count (CBC) test evaluates all the elements in the blood, including the RBC’s (Red Blood Cells), WBC’s (White Blood Cells) and Platelets. Platelet Count (PC) test measures the overall quantity of Platelets in the blood. Coagulation test evaluates the blood’s clotting ability and the clotting time. Urine Test examines urinary tract infections, any trace of bacteria or White blood Cells (WBC’s) in the urine. Ultrasound enables to examine any issues with the organs, tissues and blood vessels without taking an incision. Biopsy of the Bone marrow is removal of the marrow from the bones to examine any disorders of the bone marrow, blood and cancer detection. X-rays examine various body parts, bones and joints, issues with the soft tissue and intrinsic organs.

Treatment

For serious conditions of bleeding underneath the skin or bruising, or ones caused due to an underlying medical problem, a doctor might recommend a customised medical treatment plan. Surgical operations are carried out in case of large hematomas (swelling due to the blood clot in the tissues). While there are no particular methods to prevent minor cases of internal bleeding or bruising, following home therapies can help in healing:

1.) Application of an ice-pack on the affected site for few minutes immediately, upon noticing any internal bleeding blotches and repeating the same couple of times a day.

2.) Keeping the bruised area/patch uncovered to promote faster drying and healing.

3.) Preventing the bruised patches from being exposed to hot shower baths/sauna treatments for at least for 2-3 days.

4.) Application of heat compress to the affected surface for 15 to 20 minutes couple of times in a day, only after the inflammation has subsided.

5.) Gentle rubbing and massaging on the bruised and peripheral area, only as the pain and swelling soothes down.

6.) Including plenty of fruits, all kinds of vegetables, rich in vitamins and anti-oxidants to prevent vitamin deficiency, which causes internal bleeding.

7.) Avoid smoking and consumption of tobacco-based products.

8.) Non-consumption of alcohol upon developing the condition.

9.) Abstaining from vigorous exercise/workouts/heavy lifting/strenuous activities upon developing the condition.

10.) Application of herbal gels/creams (such as Arnica-based counterirritants) on the affected surface, until the bruising/blotching heals.

11.) Baths using Epsom salts help in relaxing muscles and reducing inflammation caused by bruising.

12.) Application of aloe-vera pulp/aloe vera based gels directly onto the affected surface of the skin too can help in soothing and healing of bruises.

13.) Application of green tea/black tea bags upon use, directly onto the bruises help in reducing discoloured botches caused due to bruises.

14.) Apple Cider vinegar has properties that help in breaking the blood clots in the bruised surface and increasing the blood flow. Thus, upon diluting it with lukewarm water, can be used as a compress.

15.) Take doses of Bromelain (200 mg), two to three times a day.

Consumption of NSAID’s are not recommended by the doctors, for conditions of internal bleeding/bruising, as it can further worsen and complicate the condition.

References

1. https://www.id-press.eu/mjms/article/view/oamjms.2017.207
2. https://onlinelibrary.wiley.com/doi/full/10.1002/ajh.23485
3. https://onlinelibrary.wiley.com/doi/full/10.1111/bjd.13198