The ecchymosis It is the purplish color that the skin takes due to the extravasation of blood from the blood vessels to the interstitial tissue. It is known colloquially as "bruise", "purple" or "black", referring to the color that the area takes when ecchymosis appears.
More than a disease, ecchymosis is a clinical sign that indicates that small blood vessels have been injured, thus allowing blood to escape from the intravascular space into the interstitial tissue..
Ecchymoses are generally associated with trauma, although they can also occur spontaneously, particularly in patients using anticoagulants..
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The pathophysiology behind ecchymosis is truly simple. After trauma, small blood vessels (arterial and venous capillaries, arterioles and venules) are totally or partially ruptured in the area of injury, allowing blood to flow from the intravascular space to the interstitial space.
It is a self-limited process since it does not take long before the normal mechanisms of hemostasis control the situation, however the blood that left the blood vessels remains in the interstitial space, giving rise to ecchymosis..
In ecchymosis, the blood "infiltrates" the subcutaneous cellular tissue, forming what could be defined as "layers", that is, healthy tissue alternates with extravasated blood in a disorganized way.
One of the most striking characteristics of ecchymoses is the different color changes that the skin takes throughout its evolution..
Although the blood is red, that color is transitory and does not take long to disappear to give way to the characteristic purple. This is because once the hemoglobin in the blood loses oxygen (which happens fairly quickly in extravasated blood) it turns from bright red to very dark red..
In large amounts, deoxygenated blood appears purple through the skin.
As time passes and throughout the process of solving the ecchymosis, the color will continue to vary. This is because the body begins to break down the hemoglobin in the extravasated blood, converting it into various pigments..
Thus, a few days after the ecchymosis has appeared, the color changes from purple to bluish-green; this is because the heme group of hemoglobin transforms into a pigment known as biliverdin.
Later the biliverdin is transformed into bilirubin giving the area a yellowish color. Eventually bilirubin is degraded to hemosiderin, which gives the skin in the affected area a light brown hue..
Finally, hemosiderin is removed from the tissue by macrophages, at which point the skin returns to its normal color..
Ecchymosis is often confused with bruises since in both cases the skin takes on a purplish tone; even some bruises can be associated with ecchymosis, but these are two different clinical entities.
In hematomas, the blood is collected in a well-defined space forming a kind of "bag", which not only can be clearly differentiated from the surrounding tissue but can also be evacuated by puncture.
In addition, the volume of blood present in hematomas is much greater than in ecchymoses since these are secondary to the injury of larger vessels; for this same reason bruises tend to be located in deeper planes than ecchymosis.
The reason why some hematomas (especially large ones) are associated with ecchymosis is that part of the blood contained in the "sac" that limits the hematoma leaks (as a result of pressure) into the surrounding tissue, infiltrating it from diffuse way.
In general, ecchymoses tend to appear in the most declining areas, because the blood tends to go downwards due to its own weight, which implies that the ecchymosis area includes the site of the trauma and an extension beyond it, precisely towards declining areas.
Ecchymosis itself is a symptom, which is usually associated with pain and inflammation of the affected area, especially in cases of trauma.
In some patients with spontaneous ecchymoses due to anticoagulant therapy or autoimmune diseases, pain and inflammation may be absent or minimal..
Depending on the intensity of the trauma, in addition to pain and inflammation (local increase in volume), a rise in temperature in the affected area may occur, although this is not usually significant or last too long.
The main cause of ecchymosis is moderate intensity trauma, that is, those that have the ability to injure the small vessels of the skin and subcutaneous cellular tissue without compromising the larger vessels..
Likewise, ecchymosis can occur in patients with long bone fractures, muscle tears, and even tendon and ligament ruptures. In these cases, blood flows from the injured structures to the subcutaneous cellular tissue, infiltrating it without being collected (since otherwise it would generate a hematoma).
Postoperative ecchymoses may also occur in patients undergoing surgery, either due to injury to small-caliber vessels in the incision area, improper tissue management or bone sectioning as occurs in orbit surgery. nose and some cases of dental surgery; in the latter case, ecchymosis occurs on the oral mucosa instead of on the skin.
Finally, it is possible that spontaneous ecchymoses may occur in patients with coagulation disorders, either due to the use of anticoagulant medications (warfarin, heparin, etc.) or due to medical conditions that compromise coagulation (purpura, hemophilia, etc.).
In these cases, in general, the patient does not report any trauma and even so, ecchymosis occurs, which is due to the fact that the energy required to injure the vessels is much lower; therefore, coughing, a sneeze or simply a tight garment are enough to injure the vessels and cause ecchymosis to appear "spontaneously".
In general, a specific treatment for ecchymosis is not necessary, in most cases the application of local cold (ice pack, cold compresses) is enough to alleviate the symptoms, being associated in the most severe cases mild analgesics such as acetaminophen.
Some medical professionals advise the use of heparinoid ointments to accelerate the resolution of ecchymosis, however there are no scientific studies that demonstrate that such a therapeutic strategy is effective..
What is important is to correct the cause in cases of spontaneous ecchymoses whenever possible..
In cases of anticoagulation, this implies correcting the doses of anticoagulants so that the patient is in the anticoagulation range but without bleeding risk, while in diseases that present with coagulation defects, appropriate therapeutic measures must be instituted to prevent bleeding complications.
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