ecchymoses

Ecchymoses result from blood leaking from damaged blood vessels into the dermis or subcutaneous tissue, producing a flat, non-blanching discoloration that evolves through characteristic color changes (red/purple → blue/black → green → yellow → brown) as hemoglobin is broken down to biliverdin and bilirubin over 1-3 weeks. Unlike petechiae (pinpoint, <3mm) and purpura (3mm-1cm), ecchymoses are larger (>1cm) and often result from trauma, though they can also indicate underlying coagulopathy, vasculitis, or platelet dysfunction when they appear spontaneously or disproportionate to trauma.

Clinical significance: Easy or spontaneous ecchymoses bruising should prompt evaluation for bleeding disorders including thrombocytopenia (ITP, TTP, DIC), coagulation factor deficiencies (hemophilia A/B, von Willebrand disease), liver disease (decreased clotting factor synthesis), vitamin K deficiency, anticoagulant use (warfarin, heparin, DOACs), vascular fragility (Ehlers-Danlos syndrome, scurvy, senile purpura), or vasculitis (Henoch-Schönlein purpura, which causes palpable purpura).

Key associations for boards: Child abuse (bruises in unusual locations or patterns, multiple ages), elder abuse, battle sign (mastoid ecchymosis) and raccoon eyes (periorbital ecchymosis) indicating basilar skull fracture, Cullen sign (periumbilical ecchymosis) and Grey Turner sign (flank ecchymosis) indicating retroperitoneal hemorrhage (e.g., hemorrhagic pancreatitis), and coagulation studies (PT/PTT, platelet count) should be ordered when bleeding disorder is suspected.