Bruising — Easy / Unexplained Algorithm

Safety

Red Flags — Exclude Serious Haematological and Safeguarding Emergencies

Done

Bruising is a symptom of a haemostatic disorder — from benign to life-threatening. Screen for the can't-miss diagnoses before anything else. Consider safeguarding in children and vulnerable adults. Do not delay emergency transfer to complete primary-care investigations.

Spontaneous large haematomas Especially if deep-tissue, no trauma, or joints/muscles — haemophilia, acquired haemophilia/factor inhibitor → Same-day haematology/hospital discussion; rapidly expanding, airway-threatening oral bleeding or suspected compartment syndrome → 999

Non-blanching rash + fever or seriously unwell Suspected meningococcal disease (any age) → 999

Thrombocytopenia <20 × 10⁹/L Particularly if new or associated with bleeding → Same-day haematology/hospital discussion (practical local threshold, not a NICE standard)

Bruising + pallor, fatigue, fever, infection or lymphadenopathy Possible acute leukaemia or marrow failure → Consider very urgent FBC (48 h) · NICE NG12; pancytopenia, blasts or a count/film suggesting leukaemia → Immediate specialist assessment

Concerning bruising in a child Not independently mobile; patterned, linear or clustered; ears, eyes, neck, cheeks, buttocks or other protected areas; hand, grip, ligature, implement or bite shape; inconsistent with history or development — suspect maltreatment (NICE CG89) and also consider medical causes → Urgent senior paediatric / safeguarding assessment (local pathway)

Bruising + active bleeding Major or critical-site bleeding (intracranial, GI, retroperitoneal), haematemesis/melaena, significant haemoptysis, syncope or haemodynamic compromise; suspected DIC/thrombotic microangiopathy with systemic illness → 999 — do not delay for GP tests

Warfarin/DOAC + major bruising Significant bleeding → same-day hospital assessment; major bleeding → 999 (reversal is hospital-led). Minor bruising → review INR, adherence, renal function and interactions per local anticoagulation protocol → Urgency by bleeding severity

Unexplained bruising in frail elderly Consider elder abuse. Ask about safety at home, who administers medication. If concern → safeguarding referral → Safeguarding assessment

Weight loss + bruising + lymphadenopathy B-symptoms + bruising — lymphoma, leukaemia → Consider very urgent FBC (48 h) · consider suspected cancer referral for lymphoma · NICE NG12

Suspected HIT Recent heparin exposure with a significant platelet fall and/or thrombosis → Same-day haematology discussion

Non-blanching petechiae in a febrile child is meningococcal septicaemia until proven otherwise — treat as an emergency (999). Bleeding risk depends on platelet count, rate of fall, cause, platelet function, anticoagulant exposure and clinical context — a count <20 × 10⁹/L, especially if new or with bleeding, warrants same-day discussion. Acute promyelocytic leukaemia (APML) presents with bruising, petechiae, and DIC — it is rapidly fatal without treatment but highly curable with urgent ATRA therapy. Non-accidental injury in children must be actively considered — bruising in a child who is not independently mobile should prompt suspicion of maltreatment (NICE CG89), while also considering medical causes such as a bleeding disorder — both can coexist. In adults on anticoagulation, unexpected bleeding patterns may reflect drug interactions, renal impairment, or excessive dosing.

Diagnose

Focused History — Characterise the Bleeding Tendency

Done

Use history to distinguish platelet disorders (superficial, mucocutaneous) from coagulation disorders (deep, delayed) — they look and behave very differently.

Character of bleeding

Platelet number/function disorder or VWD: petechiae, gum bleeds, epistaxis, menorrhagia — immediate on injury, superficial. Coagulation-factor deficiency or inhibitor: deep haematomas, haemarthroses, delayed bleeding after surgery/dental extraction. Actinic purpura: confined to sun-damaged extensor forearms/hands with fragile skin. Palpable purpura + arthralgia, abdominal pain or renal symptoms → vasculitis (IgA vasculitis in children). Also ask about haematuria, rectal bleeding, haematemesis, melaena, haemoptysis, menorrhagia, post-coital or intermenstrual bleeding

Duration

Lifelong since childhood → congenital (von Willebrand disease, haemophilia). New onset in adult → acquired (medication, ITP, liver or renal disease, acquired factor inhibitor, nutritional deficiency, marrow disease, malignancy). Ask about bleeding after dental extraction, surgery, childbirth, circumcision or significant injury

Drug history

Essential (prescribed, OTC, recreational): aspirin, NSAIDs, clopidogrel/other antiplatelets, warfarin, DOACs, heparins, SSRIs/SNRIs, systemic/inhaled/potent topical steroids, antibiotics, antifungals and recent medication changes, herbal products (ginkgo, garlic, fish oil), alcohol quantity, binges and dependence. Do not advise stopping anticoagulant/antiplatelet treatment solely because of bruising without considering indication and thrombotic risk. Ask specifically — patients often don't volunteer

Family history

First-degree relatives with bleeding tendency, joint bleeds, excessive surgical bleeding → haemophilia (X-linked recessive), VWD (autosomal dominant). A negative family history does not exclude an inherited bleeding disorder

Surgical/dental history

"Did you bleed a lot after tooth extraction or surgery?" — useful screen for an inherited bleeding disorder; also ask about childbirth, circumcision and significant injury

Alcohol and liver disease

Alcohol causes thrombocytopenia (direct toxic + hypersplenism) and impairs coagulation factor synthesis. Heavy drinkers commonly bruise easily

Systemic illness

Liver/alcohol-related disease and splenomegaly; renal disease (platelet dysfunction); autoimmune disease or HIV risk (ITP); recent infection; weight loss, fever, night sweats, fatigue or recurrent infection; malnutrition, food insecurity or malabsorption (vitamin K/C deficiency); hypermobility, abnormal scarring or skin fragility; Cushing's; pregnancy or possible pregnancy

Menstrual history

Menorrhagia from puberty onwards is a classic VWD presentation. ISTH-BAT (Bleeding Assessment Tool) score ≥6 in adult women (≥4 in men, ≥3 in children) suggests a significant bleeding disorder

The Bleeding Assessment Tool (BAT) is a validated scoring instrument (ISTH-BAT) that quantifies bleeding history — abnormal scores are ≥4 in adult men, ≥6 in adult women and ≥3 in children (international ISTH/SSC cut-offs). Von Willebrand disease affects 1 in 100 people — it is the most common inherited bleeding disorder and is frequently missed because symptoms are mild and often attributed to "normal" periods. Steroids cause skin fragility through collagen loss, producing purpura without a haemostatic defect — this is benign and requires no investigation. Drug history is the single most important first step — aspirin, NSAIDs, and SSRIs are enormously common and frequently overlooked causes.

Diagnose

Classify Bruising Type — Mechanism and Likely Category

Done

Classification drives investigation and urgency. Most GP bruising presentations fall into one of five categories.

Senile/steroid purpura

Atrophic skin + sun damage + extensive steroid use. Thin skin tears easily. Forearms/dorsal hands. Recurrent, sharply demarcated purple ecchymoses. Generally benign and self-limiting — reassure; reconsider the diagnosis if distribution or bleeding history is atypical

Drug-induced thrombocytopenia or platelet dysfunction

Temporal relationship to new drug. Petechiae, mucosal bleeds. Platelet count low or borderline. Review the drug (do not stop essential anticoagulant/antiplatelet treatment reflexively); urgent FBC and discuss significant abnormalities; repeat counts after withdrawal only where clinically safe and per local advice. Common culprits: quinine, heparin, valproate, trimethoprim

Immune thrombocytopenia (ITP)

Diagnosis of exclusion: isolated thrombocytopenia (<100 × 10⁹/L), normal coagulation, after excluding pseudothrombocytopenia, marrow disease, infection, drugs and other secondary causes — discuss with haematology. Wet purpura (oral blood blisters) is a high-risk sign. Can be primary or secondary (HIV, Hep C, SLE, CLL)

Inherited bleeding disorder

VWD (commonest; low VWF antigen + activity); haemophilia A (FVIII low, X-linked males); haemophilia B (FIX low). Lifelong history; family history may be negative. Normal PT/APTT and platelet count do not exclude VWD or a platelet-function disorder — refer to haematology for specialist testing if the history is convincing (UKHCDO/BSH 2024)

Systemic / acquired coagulopathy

Liver disease (all factors ↓ except FVIII + vWF); DIC (sepsis, cancer, obstetric emergency); vitamin K deficiency (malabsorption, antibiotics, poor diet) — INR/PT raised. Acquired haemophilia/factor inhibitor (new spontaneous deep bleeding, isolated prolonged APTT) and HIT (recent heparin + platelet fall ± thrombosis) → same-day haematology discussion

Vascular / connective tissue

Ehlers-Danlos syndrome (hyperelastic skin, hypermobile joints, normal bloods); IgA vasculitis (Henoch-Schönlein purpura: palpable purpura with arthralgia, abdominal pain or renal symptoms — particularly children); scurvy (perifollicular)

Benign easy bruising

Common in young women. No bleeding history, no family history, normal FBC + coagulation. Diagnosis of exclusion. Reassure after investigation if normal

Accurate classification prevents both under- and over-investigation. Typical actinic (senile) purpura with no bleeding history and a reassuring assessment does not need a full coagulation screen. ITP can be secondary — consider HIV, hepatitis C, SLE and CLL, testing with consent and per local policy when ITP is suspected. Heparin-induced thrombocytopenia (HIT) is a paradoxical prothrombotic emergency despite low platelets — urgent haematology involvement is required. Scurvy (vitamin C deficiency) is under-diagnosed in the UK among elderly patients, alcohol-dependent individuals, and those with restricted diets — look for perifollicular haemorrhages and corkscrew hair.

Diagnose

Targeted Examination — Bruise Assessment and Systemic Signs

Done

Examination is not just about the bruises — look for systemic clues to the underlying cause.

Bruise characterisation

Number, size, colour, age and site; palpable, blanching or non-blanching; distribution (sun-exposed/extensor, dependent, flexural or protected areas); shape (patterned, linear, geometric or clustered — consider inflicted injury); depth (superficial = platelet; deep = coagulation)

Petechiae vs purpura

Petechiae: <2 mm pin-point, non-palpable, non-blanching — platelet disorder. Purpura: 2–10 mm, may be palpable — vasculitis (HSP). Ecchymosis: >10 mm bruise. Document and size

Skin assessment

Skin fragility/atrophy (steroid/actinic purpura). Hyperelastic skin + hypermobile joints → Ehlers-Danlos. Jaundice/spider naevi → liver disease. Cushingoid appearance

Oral cavity

Wet purpura (blood blisters on buccal mucosa) is a high-risk sign requiring urgent assessment; platelet count and clinical context determine urgency. Gum hypertrophy with bleeding → leukaemia

Lymphadenopathy + spleen

Lymphadenopathy, hepatomegaly or splenomegaly + bruising → lymphoma/leukaemia. Splenomegaly → portal hypertension / haematological malignancy / hypersplenism causing thrombocytopenia

Joint examination

Haemarthrosis (swollen, warm joint) without trauma → haemophilia or acquired factor inhibitor (same-day discussion). Hypermobility assessment → EDS. Arthralgia + purpura → HSP/vasculitis

Safeguarding indicators

In children: bruises on ears, eyes, neck, cheeks, buttocks or protected areas, patterned/clustered, or in a non-mobile child — examine fully and record size, site, colour, shape and developmental mobility. Photograph only via approved clinical systems per local policy, consent and safeguarding procedures. Consult the safeguarding lead and follow the local pathway

Nutritional assessment

Perifollicular haemorrhage + corkscrew hair → scurvy (vitamin C deficiency). Assess diet, alcohol intake, social circumstances. Check gum bleeding

Neurology / concealed bleeding

Neurological status and signs of concealed bleeding where relevant (e.g. headache with thrombocytopenia or anticoagulant exposure)

The site of bruising is the most important clinical discriminator — typical actinic purpura on sun-damaged forearms with no bleeding history is generally benign (reconsider if atypical). Bruising on the ear, neck or other protected areas, or in a child who is not independently mobile, should prompt suspicion of maltreatment (NICE CG89) alongside consideration of medical causes. Wet purpura (blood blisters in the mouth) is a high-risk sign needing urgent assessment — it does not reliably prove a particular platelet count; bleeding risk depends on count, rate of fall, cause, platelet function and anticoagulant exposure. Gum bleeding with gum hyperplasia in a young adult is leukaemia until proven otherwise — gum infiltration by leukaemic blast cells is a classic AML presentation.

Diagnose

Investigations — Haematological Workup

Done

NICE NG12: consider a very urgent FBC (within 48 hours) for adults with unexplained bruising, bleeding or petechiae — a test recommendation, not an automatic haematology referral. Do not withhold first-line bloods in a patient with concerning bruising.

FBC with differential All new unexplained bruising ± blood film

Platelets: normal ≥150 × 10⁹/L; mild thrombocytopenia 100–150; <100 more significant. Blood film where thrombocytopenia, anaemia, leucopenia, abnormal indices or systemic features are present, or if the laboratory requests: blast cells (leukaemia), schistocytes (TTP/DIC), atypical lymphocytes (viral/CLL)

Coagulation screen Significant, recurrent or unexplained bleeding

PT/INR (extrinsic pathway: liver, vitamin K, warfarin, factor VII). APTT (intrinsic pathway: haemophilia A/B, heparin, lupus anticoagulant). Fibrinogen (DIC, liver failure)

U&E + LFTs

Renal failure (platelet dysfunction, uraemic bleeding). Liver disease (↓ albumin, ↑ bilirubin, ↑ LFTs, impaired factor synthesis). GGT as alcohol marker. CRP/ESR if inflammatory, infective or systemic disease is suspected

TFTs

Not routine first-line for bruising — test only if clinically indicated

Vitamin B12, folate

If macrocytosis, anaemia, malnutrition or pancytopenia. Macrocytic anaemia + thrombocytopenia → consider B12/folate deficiency, bone marrow pathology, or excess alcohol

von Willebrand studies Specialist

VWF antigen, VWF ristocetin cofactor activity, FVIII — haematology arranges. Not indiscriminately for every bruise — haematology arranges when the bleeding history is convincing despite normal first-line results (a normal APTT does not exclude VWD; UKHCDO/BSH 2024)

HIV, hepatitis B/C & other tests

HIV and hepatitis B/C when ITP/secondary causes, liver disease, risk factors or relevant features are present — with consent and per local testing policy. Pregnancy test where appropriate; urinalysis if vasculitis, renal disease or haematuria suspected; immunoglobulins/autoimmune tests only if indicated, preferably after haematology discussion

Do NOT routinely order

Platelet function analysis/PFA-100 — not a reliable screening test for mild platelet disorders. D-dimer — non-specific. ANA without clinical indication. Bone marrow biopsy from primary care. VWD studies indiscriminately in every patient with a bruise

Isolated low platelets

First exclude platelet clumping/artefact, recent infection, alcohol, liver disease/hypersplenism, medication, HIV or hepatitis C where relevant, pregnancy-related causes and marrow disease. Repeat FBC and request a film if unexpected or clinically discordant. Urgent referral for severe thrombocytopenia, bleeding, blasts, red-cell fragments, pancytopenia or systemic features

A normal FBC and coagulation screen in a patient with easy bruising, no relevant history, and normal examination makes a serious haematological disorder less likely — but does not exclude VWD or a platelet-function disorder if the history is convincing. The blood film is cheap and profoundly informative — it must be specifically requested with FBC; automated analysers alone cannot reliably detect blast cells, schistocytes, or atypical lymphocytes. International (ASH/ISTH/NHF/WFH 2021) VWD guidance uses an abnormal ISTH-BAT to select patients for von Willebrand studies — VWD is underdiagnosed in women with heavy periods. TFTs are not a routine bruising test — request only when clinically indicated.

Refer

Referral Criteria — Urgency and Destination

Done

Platelet thresholds below are practical local safety thresholds, not a NICE referral algorithm — local haematology advice determines destination and urgency. Use results alongside the clinical picture.

999

Active major haemorrhage or haemodynamic compromise; suspected intracranial, GI, retroperitoneal or other critical-site bleeding; severe headache, neurological symptoms, collapse or reduced consciousness with thrombocytopenia or anticoagulant exposure; haematemesis, melaena, significant haemoptysis or bleeding causing syncope; suspected DIC/thrombotic microangiopathy with systemic illness; suspected meningococcal disease (non-blanching rash with fever or seriously unwell); rapidly expanding deep haematoma, airway-threatening oral bleeding or suspected compartment syndrome. Do not delay transfer for primary-care tests

Same-day haematology / hospital discussion

Platelets <20 × 10⁹/L, particularly if new or with bleeding; active mucosal bleeding, oral blood blisters or widespread petechiae; blasts or concerning film (immediate specialist assessment); pancytopenia, significant anaemia, neutropenia or rapidly falling platelets; spontaneous deep haematoma, haemarthrosis or muscle bleeding; suspected acquired haemophilia/factor inhibitor; suspected HIT (recent heparin + significant platelet fall and/or thrombosis); significant bleeding on warfarin, a DOAC or an antiplatelet

Suspected cancer · haematology

NICE NG12 (updated April 2026): consider a very urgent FBC (within 48 hours) for adults with unexplained bruising, bleeding or petechiae, pallor, persistent fatigue, unexplained fever or recurrent infection, generalised lymphadenopathy or hepatosplenomegaly; children and young people with unexplained petechiae or hepatosplenomegaly → immediate specialist assessment; blood count or film suggesting leukaemia → immediate specialist assessment. The very urgent FBC is a test recommendation, not itself an automatic haematology referral — act on the result (suspected haematological malignancy pathway if abnormal). Local practical (non-NICE) triggers: unexplained pancytopenia, B-symptoms + bruising or progressive thrombocytopenia → urgent haematology discussion

Urgent haematology advice/referral

Platelets <50 × 10⁹/L, falling, or with anaemia/neutropenia → same-day or urgent discussion depending on clinical state. Platelets 50–100 × 10⁹/L, stable and asymptomatic → urgent advice/referral per local pathway. Suspected ITP (do not start steroids). Abnormal PT/APTT without an obvious medication-related cause → urgent discussion

Routine haematology

Suspected inherited bleeding disorder or VWD with a convincing history — refer even if screening tests are normal. Stable diagnosed VWD. Mild haemophilia (carrier status investigation). Investigation of menorrhagia with bleeding history. Confirmed ITP (stable platelet >50) for surveillance

Safeguarding referral

Child: assess immediate safety and clinical stability; take a careful, open, non-leading history; examine fully and document precisely (size, site, colour, shape, developmental mobility); consult the practice safeguarding lead/designated professional and follow the local pathway; do not confront an alleged perpetrator; do not delay urgent paediatric or safeguarding referral awaiting bloods; arrange paediatric/haematology assessment if a bleeding disorder is possible — both can coexist. Adult at risk: local adult safeguarding pathway (may require MASH referral)

Primary care manage

Actinic purpura: reassure and educate. Aspirin/NSAID-induced: review drug necessity. Drug-induced (non-serious): review drug (do not stop essential antithrombotics reflexively), repeat FBC where safe. Clinically diagnosed scurvy: replace per local guidance, dietary advice

ITP should be referred to haematology before initiating corticosteroid treatment — secondary causes must be excluded first, and bone marrow biopsy may be needed in patients >60 to exclude MDS. Starting steroids empirically in AML can cause dangerous delays. HIT (type II) is a life-threatening prothrombotic complication of heparin — platelet count falling >50% from baseline on heparin exposure requires immediate specialist input as all heparin products must be stopped and alternative anticoagulation started. The 4T score (Thrombocytopenia, Timing, Thrombosis, oTher causes) is a validated tool for estimating HIT probability. Elder abuse is under-recognised — clinicians must be vigilant at every presentation of bruising in this group.

Treat

Treatment — Primary Care Manageable Causes

Done

Definitive treatment of most coagulopathies requires haematology. Primary care manages modifiable causes and anticoagulation per the local anticoagulation service protocol; ITP, VWD and anticoagulant reversal are specialist/hospital-led.

Warfarin — supratherapeutic INR

INR 5–8, no bleeding: omit 1–2 doses

Use the local anticoagulation service protocol. INR 5–8 without bleeding: omit 1–2 doses, reduce the subsequent dose and recheck promptly. INR >8 without bleeding: stop warfarin, give oral vitamin K (phytomenadione) per BNF and local protocol, recheck within 24 h. Minor bleeding with INR >5: stop warfarin and arrange same-day vitamin K per BNF and the local anticoagulation protocol (BNF route: slow IV). Significant or major bleeding: emergency hospital management (IV vitamin K + four-factor PCC where indicated; FFP not routine when PCC available). Investigate unexpected bleeding even when the INR is therapeutic. Review dose and interactions.

DOAC — bleeding on therapeutic dose

Minor bruising: review · major: hospital

Minor bruising: assess adherence, dose, renal function and interactions; FBC/U&E/LFT where indicated; avoid NSAIDs and unnecessary antiplatelets; do not routinely measure PT/APTT to quantify DOAC effect; seek advice if recurrent, unexplained or with anaemia. Severe/major bleeding: stop further doses and arrange emergency hospital assessment; record agent, dose, time of last dose, renal function and indication. No reversal in primary care — reversal is hospital-led and carries thrombotic risk (idarucizumab for dabigatran; andexanet alfa only per NICE TA697 for life-threatening or uncontrolled GI bleeding on apixaban/rivaroxaban).

Vitamin C deficiency (scurvy)

Ascorbic acid — dose per local guidance if clinically diagnosed

Avoid a universal regimen unless scurvy is clinically diagnosed; check dose against local prescribing guidance/product information. Dietary advice: citrus fruit, kiwi, peppers. Address underlying social causes (poverty, food insecurity, alcohol dependence).

Drug-induced (aspirin/NSAID)

Medication review

Establish the temporal relationship; review all prescribed and non-prescribed medicines. Assess necessity vs thrombotic risk — do not stop essential anticoagulant/antiplatelet treatment reflexively. If aspirin not indicated: stop. If NSAID: switch to paracetamol where possible. SSRIs + anticoagulants: monitor closely. If thrombocytopenia suspected: urgent FBC and discuss significant abnormalities.

Actinic / steroid purpuraExplain it is usually benign; review need and dose of corticosteroids; review antithrombotics without stopping unless indication and risk assessed; sun protection, protective clothing, avoid skin trauma; dermatology if atypical, ulcerated, persistent or diagnostically uncertain.

ITPDiagnosis of exclusion — discuss with haematology. Do not start prednisolone in primary care because the platelet count is low; treatment is haematology-led and based on bleeding, platelet trend, comorbidity and procedural requirements, not the count alone. Prophylactic platelet transfusion is generally not appropriate; transfusion for serious bleeding only under specialist direction.

Suspected VWD / inheritedRefer rather than treating empirically with desmopressin — response varies by subtype and it may be contraindicated (including some type 2 variants). Haematology guides VWF antigen/activity, factor VIII and other assays, platelet-function testing, and treatment for dental procedures, surgery, pregnancy or significant bleeding. Tranexamic acid may help mucosal bleeding or heavy menstrual bleeding (NICE NG88) — assess renal function, thrombotic risk and bleeding site; generally avoid in significant urinary tract bleeding (obstructing clots).

HaemophiliaFactor replacement managed entirely by haemophilia centre. Primary care role: avoid aspirin/NSAIDs; avoid IM injections; prescribe factor infusion products as directed by centre; provide emergency letter.

Liver disease coagulopathyTreat underlying liver disease. Correct coagulopathy according to the underlying cause and specialist guidance (no routine primary-care vitamin K regimen). Severe coagulopathy with bleeding → 999 (FFP/PCC required).

Next steps: see DOACs, antiplatelets and anticoagulation · Haematological cancers · Heavy menstrual bleeding · Harmful drinking and alcohol dependence

Tranexamic acid (antifibrinolytic) can be useful for mucosal bleeding in VWD and ITP (check renal function, thrombotic risk and bleeding site) — NICE NG88 (heavy menstrual bleeding, 2018, updated July 2026) includes tranexamic acid as a pharmacological option, and haematology uses it alongside hormonal therapy for menorrhagia in bleeding disorders. Scurvy is treatable and curable within weeks — failure to diagnose it in socially isolated elderly patients and those with alcohol dependence is a recurrent Serious Incident finding in the UK. Andexanet alfa (Ondexxya) is recommended in NICE TA697 (May 2021) for reversal of apixaban or rivaroxaban only in life-threatening or uncontrolled bleeding in the gastrointestinal tract (the intracranial-haemorrhage appraisal, TA1029, was terminated) — hospital-led; not a primary-care treatment or routine for all major bleeds or intracranial haemorrhage. Idarucizumab (Praxbind) reverses dabigatran within minutes. Primary care GPs must never start steroids for presumed ITP without haematology input — the clinical and diagnostic consequences of treating AML or lymphoma with immunosuppression are catastrophic.

Lifestyle

Non-Pharmacological Interventions and Patient Education

Done

Lifestyle advice is essential regardless of cause — for safety, treatment optimisation, and preventing further injury.

Alcohol reduction / cessation Alcohol directly suppresses platelet production (thrombocytopenic within days of binge), impairs coagulation factor synthesis, and increases falls/injury risk. Target <14 units/week. AUDIT score. Refer if dependent.

Falls prevention Patients on anticoagulation with bruising are at high risk from falls. Refer to falls prevention service. Home hazard assessment. Review medications causing postural hypotension. Hip protectors if osteoporotic.

Medication awareness Educate: avoid aspirin, NSAIDs, ibuprofen (OTC) unless prescribed. Check interactions with anticoagulants (antibiotics, antifungals). Patients on anticoagulants should know the medicine, dose and indication and carry an anticoagulant alert card or medical information; medical ID for bleeding disorders.

Skin protection Actinic/steroid purpura: protective clothing (long sleeves), SPF 50+ on exposed skin, moisturisers to reduce fragility. Avoid skin trauma. Barrier creams for forearm protection in elderly.

Dietary optimisation Vitamin K food sources (leafy greens) — counsel warfarin patients on consistent dietary intake, not avoidance. Vitamin C: ensure adequate dietary intake (citrus, peppers, kiwi). Balanced diet reduces multiple deficiencies.

Activity modification (haemophilia) Contact sports and IM injections are contraindicated. Swimming, cycling, and walking are safe. Joint protection advice. Physiotherapy for joint management. Inform haemophilia centre of any planned procedure.

Anticoagulation monitoring Warfarin: INR monitoring per the local anticoagulation service. DOAC: review at least annually — more often if older, frail or renally impaired — using Cockcroft–Gault creatinine clearance for dosing rather than eGFR automatically. Assess interactions by individual drug and product information. Alert to bleeding symptoms.

Psychological impact Unexplained bruising causes significant anxiety. Bruising from haematological malignancy treatment causes body image distress. Address these explicitly. Haemophilia societies provide peer support (Haemophilia Society UK).

Alcohol-related thrombocytopenia is directly dose-dependent — complete abstinence can normalise platelet count within 1–2 weeks. Falls in patients on anticoagulation can cause major haemorrhage — falls prevention is a critical safety intervention. DOACs (dabigatran, rivaroxaban, apixaban, edoxaban) do not require routine coagulation monitoring (BNF/SPC) — but renal function should be checked at least annually (more often if older, frail or renally impaired) as dose thresholds are based on Cockcroft–Gault CrCl (rivaroxaban in AF: reduce to 15 mg OD if CrCl 15–49 mL/min; apixaban: specific criteria based on weight + creatinine). All patients with a diagnosed bleeding disorder should receive a haemophilia society information pack and emergency management instructions to present to any emergency clinician.

Safety

Follow-Up, Monitoring and Safety-Netting

Done

Follow-up interval depends on the underlying cause and the severity of thrombocytopenia or coagulopathy.

1 week

Drug-withdrawn thrombocytopenia: repeat FBC where clinically safe and per local advice — platelet count should be rising. Warfarin dose adjustment: recheck INR. Any patient awaiting a suspected cancer haematology appointment: confirm appointment received

2–4 weeks

Suspected drug-induced: FBC + LFTs — confirm resolution. Scurvy: symptomatic improvement expected. Vitamin B12 replacement initiated: early FBC improvement

3 months

Stable ITP under haematology: GP to be kept in loop. Anticoagulation review: bleeding events? Falls? Dose adherence? Annual renal function for DOAC patients

Annual

DOAC: at least annual U&E with Cockcroft–Gault CrCl for dosing (more often if older, frail or renally impaired). Warfarin: INR stability review, liver function, check indications still valid. VWD under haematology: bleeding symptom review. Haemophilia: joint surveillance

FBC threshold to act

Local practical thresholds (not NICE standards): platelets <20 × 10⁹/L → same-day discussion; <50 or falling → same-day or urgent discussion depending on clinical state; 50–100 stable and asymptomatic → urgent advice/referral per local pathway. Stable 100–150 with no other abnormality → individualised monitoring plan (not automatically 4-weekly)

Safety-net 999

Severe headache, confusion, collapse or neurological symptoms (especially if thrombocytopenic/anticoagulated); major gastrointestinal bleeding (haematemesis, melaena) or significant haemoptysis; haemodynamic compromise; suspected meningococcal disease (non-blanching rash with fever or seriously unwell); significant bleeding while anticoagulated; severe joint bleed with neurovascular compromise. Any head injury while anticoagulated → A&E straight away, even if well

Safety-net same-day

New widespread petechiae; oral blood blisters; bleeding that does not stop with sustained pressure; nosebleed lasting >10–15 minutes despite pressure (A&E); rapidly increasing bruising; haematuria or significant rectal bleeding; new deep muscle or joint swelling; bruising with fever, pallor, marked fatigue, lymphadenopathy or weight loss

Patient card / alert

Patients on anticoagulants should know the medicine, dose and indication; those on anticoagulants or with a known bleeding disorder should carry an anticoagulant alert card and the NHS oral anticoagulant therapy (yellow) booklet. Haemophilia patients: emergency management card from haemophilia centre

Thrombocytopenia from drug withdrawal typically recovers within 5–14 days — a failure to improve after drug cessation should prompt urgent re-evaluation and haematology referral. Any severe headache in a thrombocytopenic or anticoagulated patient is an emergency (999). The NHS oral anticoagulant therapy booklet (yellow book, originally from the National Patient Safety Agency) is a nationally standardised patient record that should be issued to all new warfarin patients — it documents INR values and enables safe cross-prescribing between healthcare professionals. DOAC renal monitoring is mandated by manufacturers but frequently omitted — apixaban requires dose reduction to 2.5 mg BD if 2 of 3 criteria met: age ≥80, weight ≤60 kg, or creatinine ≥133 µmol/L.