A skin hematoma is a condition when a blood vessel ruptures under the skin so that blood enters the subcutaneous tissue and produces a blue-black color on the skin surface. A hematoma usually occurs as a result of trauma, but skin hematoma can also occur spontaneously. In this condition, it is necessary to consider clotting factor disorders and blood vessel disorders.

The Causes of Spontaneous Skin Hematoma
Skin Hematoma
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What are the causes of Spontaneous Skin Hematoma?

Several diseases or conditions can cause spontaneous skin hematoma, the most common of which are: iatrogenic coagulopathy, hemophilia, thrombocytopenic purpura, disseminated intravascular coagulation (DIC), Henoch Schonlein purpura (HSP), senile purpura, coagulation inhibitors, and physical injury.

1. Iatrogenic coagulopathy

One of the common causes of spontaneous hematoma is iatrogenic coagulopathy. In this condition, the use of anticoagulant drugs ( such as warfarin, aspirin, and clopidogrel) causes blood coagulation disorders. The bleeding risk of anticoagulant therapy can increase when used together with other drugs, such as antidepressants, antibiotics, and even digestive drugs such as cimetidine and omeprazole.

The use of these drugs is increasingly being used nowadays, so doctors need to pay attention to the effects of these drug interactions. Patients should be closely monitored to determine the risk of bleeding, especially at the initiation of therapy and changing the dose.


2. Hemophilia

Hemophilia is a disease in which the blood cannot clot properly. The hemophilia spectrum ranges from mild to severe. Severe hemophilia has been visible since neonates, especially in the joints (hemarthrosis). Moderate degrees can appear later in life with spontaneous bleeding symptoms, such as pain in the weight-bearing joints due to hemarthrosis. Generally, this condition is rare. Meanwhile, symptoms and signs of mild hemophilia only appear during trauma or after surgery.

Hemophilia is an X-linked inherited disease that interferes with the function of clotting factors. Patients with hemophilia A have FVIII deficiency, and patients with hemophilia B have factor IX deficiency.

Patients with hemophilia may experience spontaneous skin hematoma or due to minor to major trauma, depending on the severity of the clotting factor disorder experienced. Another characteristic of hemophilia that can differentiate it from other diseases is prolonging the APTT value with the normal PT value.


3. Thrombocytopenic Purpura

Thrombocytopenic purpura can be idiopathic or have a thrombotic etiological basis. Both have a characteristic feature, namely thrombocytopenia. It is necessary to ask patients if they have a history of viral infections, upper respiratory tract infections, malignancy, and the use of antiplatelet drugs.

The acute idiopathic type rarely occurs in adults. In contrast, the thrombotic type is generally accompanied by other clinical symptoms, including neurological symptoms, decreased kidney function, and fever. This diagnosis can be excluded if the results of blood tests show normal platelet values. Currently, the idiopathic type has changed the term to the immunologic type. In this condition, the function of the spinal cord is normal.

Immune thrombocytopenic purpura (ITP) is a disease characterized by an increase in peripheral platelet destruction due to the presence of specific antibodies to platelet membrane glycoproteins. In ITP, purpura, menorrhagia, epistaxis, bleeding gums, and spontaneous hematoma are common. Laboratory results of ITP patients will show isolated thrombocytopenia. However, hemoglobin, leukocytes, coagulation factors, and bleeding time are normal.


4.Disseminated Intravascular Coagulation (DIC)

Disseminated Intravascular Coagulation (DIC) is a disease characterized by the activation of systemic blood coagulation, which can cause fibrin deposition. Thereby can cause microvascular thrombus in various organs and multiple organ dysfunction syndromes (MODS). The dermatological manifestations of DIC include the appearance of petechiae, purpura, or even spontaneous hematoma.

DIC is usually a complication or progression of other diseases, such as sepsis, trauma, malignancy, severe transfusion reactions, obstetric complications (amniotic fluid embolism, placental abruption, HELLP syndrome, eclampsia), vascular abnormalities, and liver failure.

DIC patients generally experience severe and life-threatening symptoms, such as respiratory distress, gastrointestinal bleeding, hematuria, and septic shock.


5. Henoch Schonlein Purpura

Henoch Schonlein purpura (HSP) is a vasculitis disease caused by an immunoglobulin A disorder. HSP sufferers generally complain of headaches, anorexia, fever, skin rash, joint pain, edema, and gastrointestinal bleeding.

A skin rash in erythematous macules or urticaria is an early finding in HSP patients and will turn into papules. It eventually develops purpura, which is generally symmetrical with predilection in the lower leg in adult patients. Meanwhile, in children, the predilection for lesions is often on the back, buttocks, and upper extremities. Complaints of HSP patients can disappear on their own after 6−8 weeks.


6. Purpura Senilis

Senile purpura or actinic purpura has the appearance of dark, irregular-shaped areas of the hematoma. Generally experienced by older people over 50 years of age, but can also be found at a younger age with certain conditions, for example, people with chronic obstructive pulmonary disease or autoimmune who use long-term corticosteroids.

This disorder occurs due to abnormal skin elasticity and mobility that cause small and superficial blood vessels' rupture—predilection areas on the hands and arms' extensor surfaces.

This condition is associated with the aging process due to atrophy of the perivascular connective tissue on the hands and arms' extensor surfaces, where purpura generally appears for 1–3 weeks. Additionally, senile purpura can also be caused by damage to the dermis' connective tissue due to sun exposure.

In the patient's history with senile purpura, there is no evidence of pain, pruritus, or skin discoloration in other types of purpuric lesions. Physical examination may reveal purpuric macular lesions larger than 3 mm in size. Usually found on the arm's extensor surface and on the manus's dorsum, which does not spread to the finger area, even Ecchymosis of the neck and face.

There is no need for laboratory examinations for Senile Purpura because it does not have distinctive results. On biopsy examination, a thin epidermis with abnormal keratinocytes can be found, and the outer dermis has extravasation of erythrocytes and hemosiderin without inflammatory cells.

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7. Coagulation Inhibitors

Coagulation inhibitors often occur in patients with severe congenital coagulation factor deficiency, autoimmune disease, drug sensitivity, allergies, malignancies, and in postpartum women. Early, coagulation inhibitors were thought to be rare in children. Now, children without congenital coagulation factor deficiency may experience spontaneous bleeding due to autoantibodies. There have been reports that 3% of children screened before surgery had prolonged APTT due to antibodies' presence to coagulation factors.


8. Physical injury or trauma

The most common cause of spontaneous hematoma is physical injury or trauma, including sprains, accidents, falls, injuries, and fractures. When blood vessels are damaged, blood leaks into the surrounding tissue so that the blood clots. 


Conclusion
Several different diagnoses can be considered when finding cases of spontaneous skin hematoma. Blackish-blue areas on the skin's surface that appear spontaneously without prior trauma can be caused by blood disorders, vascular disorders, or iatrogenic disorders. However, doctors should still suspect the cause of the hematoma in a patient who denies a history of trauma if symptoms and signs suggest physical trauma.


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