A person with a bruise on their upper thigh.
Credit: Izf/iStock

Rheumatoid arthritis (RA) and bruising commonly occur in tandem — for a variety of reasons. If you’ve noticed blue, black, and green spots popping up randomly on your legs, you may feel less comfortable in your own skin (and tuck away your favorite pair of shorts). Bruising is often a mystery to people with RA who wake up with new bruises without knowing the cause.

“I get bruises from time to time and have no idea why,” CreakyJoints community member Stephanie A. shared on Facebook. “I have three bruises right now on the inside of my thigh. Always a mystery.”

Skin abnormalities were reported by 61 percent of people with rheumatoid arthritis compared to just 47 percent of people who had non-inflammatory rheumatic conditions in a study in the Annals of the Rheumatic Diseases. Bruising was one of the skin issues that was more commonly reported by people with RA than controls, though it was connected to the use of steroid medications.

Many members of our community report experiencing bruising on their thighs or around trouble spots for their joints.

“I remember waking up with a bruise on my right wrist — where I have the most joint destruction — in high school, then it went away,” community member Effie K. told us on Instagram. “Thought I hit myself somewhere or bruised it while playing a sport. It was happening other places too.”

Because several factors play a role in the link between bruising and rheumatoid arthritis, it’s important to speak to your doctor if you’re experiencing frequent or easy bruising to determine the cause.

Causes of Bruising in Rheumatoid Arthritis

There are various factors that can cause bruising if you have rheumatoid arthritis — including low platelet count, medications, atrophic skin, and rheumatoid vasculitis.

Low Platelet Count

Low platelet count, also known as thrombocytopenia, occurs when you have low levels of platelets, which are colorless blood cells that help your blood clot — in particular, fewer than 150,000 platelets per microliter of blood circulating in your body. This can lead to easy or excessive bruising, per the Mayo Clinic.

A number of things can cause low platelet count, including viral infections, leukemia and other cancers, heavy alcohol consumption, and taking certain medications. Another cause may be immune thrombocytopenia, in which the body’s immune system attacks and destroys platelets by mistake, leading to greater platelet breakdown. Immune thrombocytopenia can occur in certain autoimmune diseases such as rheumatoid arthritis or lupus.

“Because rheumatoid arthritis is an inflammatory disease, when patients have high levels of inflammation in their body, we do see that some people will develop thrombocytopenia,” says rheumatologist Jiha Lee, MD, a Clinical Assistant Professor at Michigan Medicine.

Medications

If you have rheumatoid arthritis, you may also experience drug-induced thrombocytopenia, which occurs because of certain medications you’re taking to treat your rheumatoid arthritis or other conditions.

There are two types of thrombocytopenia when it’s caused by medication: immune and nonimmune. Drug-induced immune thrombocytopenia occurs when a drug causes your body to produce antibodies that destroy platelets, per the U.S. National Library of Medicine. The most common cause of drug-induced immune thrombocytopenia is heparin, a blood thinner.

Meanwhile, drugs like nonsteroidal anti-inflammatory drugs (NSAIDs) — used in rheumatoid arthritis treatment — can prevent your bone marrow from creating sufficient platelets, which is called drug-induced nonimmune thrombocytopenia.

Steroids such as prednisone can also reduce your blood’s ability to clot and lead to bruising, per Michigan Medicine.

“A lot of bruising is medication-driven,” says Dr. Lee. “Often, it’s because there are low platelet counts. Even with very minimal trauma, bruising can occur.”

Mariah Leach, founder of Mamas Facing Forward — a website and support group for mothers living with chronic illness — says she experienced many changes in her body when she was first diagnosed with rheumatoid arthritis at the age of 25. Aside from a little bit of visible joint swelling and some weight gain, she says bruises were the most obvious and visible change.

When Mariah first began experiencing excessive bruising, she brought it up with her doctor, who told her the bruising was likely a result of being on a regular dose of prednisone at the time.

“When I take a regular daily dose of prednisone, even a low dose, I do appear to bruise more easily and have deeper and more purple bruises,” she says.

Methotrexate, a disease-modifying antirheumatic drug (DMARD) commonly used to treat RA, can also cause low platelet levels. If you experience easy bruising when you’re on methotrexate, you should call your doctor immediately. This can be a sign of a methotrexate overdose, which could be fatal, per Michigan Medicine.

Atrophic Skin

You may also experience rheumatoid arthritis and bruising due to structural changes in your skin.

Rheumatoid arthritis patients can experience skin atrophy. This condition involves a reduction in the thickness of the skin’s epidermal and dermal layers, loss of fat beneath the skin, and muscle-layer atrophy, per The College of Family Physicians of Canada.

Skin atrophy can cause bruising and is an adverse effect of topical glucocorticoids, per a December 2020 review in Clinical, Cosmetic and Investigational Dermatology.

“One of the most common causes of bruising in rheumatoid arthritis patients is if somebody has been on oral steroids for a long time, because that will actually cause the collagen and fat in the skin to be broken down a little more quickly,” says Karl Saardi, MD, a dermatologist at The GW Medical Faculty Associates. “That’s how the support for the blood vessels is reduced and can cause bruising to be more pronounced and people can bruise more easily.”

In the Annals of the Rheumatic Diseases study, atrophy was found in eight patients, all of whom were on the steroid prednisolone. In those with rheumatoid arthritis, skin atrophy mostly appears over bony areas such as the shoulders.

Injection Site Reaction

If you take injectable biologic medications as part of your RA treatment plan, you might experience bruising or swelling at the injection site, per a May 2020 article in the Cleveland Clinic Journal of Medicine.

Rheumatoid Vasculitis

Longstanding and severe rheumatoid arthritis can lead to a complication known as rheumatoid vasculitis, which occurs in about 1 percent of the patient population, per Johns Hopkins Vasculitis Center.

Rheumatoid vasculitis causes inflamed blood vessels, affecting both small- and medium-sized blood vessels, per Cedars-Sinai. In rare cases, it can also affect large blood vessels. When blood vessels are damaged, they may get blocked and prevent oxygen from reaching certain parts of the body — leading to tissue problems or even death.

“That can definitely look like bruising, especially when it starts,” says Dr. Saardi. “Usually it appears on the lower legs and other parts of the extremities, too. They’re little bruises that will turn into raised purple bumps. It’s a very uncommon problem, and I personally haven’t seen it yet, but that is definitely one of the things that can happen with rheumatoid arthritis.”

Although the cause of rheumatoid vasculitis is unknown, experts believe it has to do with an autoimmune process, per Johns Hopkins. Additional symptoms can include skin ulcerations, less blood flow to the fingers or toes, numbness, tingling, focal weakness, or inflammation of the lining around the lungs or heart.

When to See a Doctor for Bruising

It’s normal to bump into something, forget about it, and then develop a bruise later. However, you should see your doctor if you start experiencing easy bruising after starting or changing dosage of a medication (like steroids or methotrexate).

“Bruising that’s unexplained, recurrent, or painful is also a reason to see a doctor,” says Dr. Saardi. “So is bruising that is associated with fever, associated with numbness or tingling in the area, rapidly spreading, or occurs after an injury with a dirty object like a tree branch.”

Many people who have rheumatoid arthritis are on medications that suppress the immune system, which can in some cases lead to unusual infections that other people wouldn’t be susceptible to. Sometimes these infections can appear purple like bruising.

Additionally, according to the Cleveland Clinic, you should see a doctor for bruising if it:

  • Shows no signs of improvement after a week
  • Is located on a part of your body where injury or accident is unlikely
  • Keeps occurring or comes back
  • Is unusually large and unprovoked

Your doctor will review your personal and family medical history. You may be asked questions such as:

  • Do any family members have an inherited blood disorder?
  • Have you been bleeding from your nose or oral cavity?
  • Have any surgeries resulted in above-average bleeding?
  • Which medications and supplements do you take; have you recently started new ones?
  • Has your menstrual flow been heavier?
  • Have you had other blood loss, such as in the urine or stool?
  • Have you ever had bleeding in unusual locations, like the joints, muscles, or brain?

If your doctor decides your bruising is likely due to medication, they may discuss switching you to another drug. However, if the cause of bruising is unclear, your doctor may run blood tests to check for platelet problems or other abnormalities in blood clotting, per the Cleveland Clinic.

How to Reduce the Appearance of Bruising

Although it can be indicative of other health issues, bruising on its own isn’t necessarily dangerous. However, it can take a toll on your self-esteem if bruises are large and frequent.

“Bruising easily is a symptom that can be associated with lots of different problems, so even if you’re pretty sure it’s happening because of rheumatoid arthritis or medications, bring it up with your doctor to be sure,” suggests Mariah. “I certainly understand how excessive bruising can impact a person’s self esteem — it didn’t make me feel particularly good about my body — but the alternative of getting off the prednisone wasn’t practical until I found another treatment that could control my pain and fatigue.”

There are a few ways you can prevent or reduce the appearance of bruising. The Mayo Clinic recommends following RICE techniques:

  • Rest: If possible, rest the bruised area.
  • Ice: Wrap an ice pack in a towel and apply to the bruised area for 10 to 20 minutes. Repeat several times per day for one to two days.
  • Compress: If the bruised area is swollen, use an elastic bandage to compress it.
  • Elevate: Raise the injured area.

“There’s been some interest in rutin [a plant compound available as a supplement], which may be helpful for conditions in which blood vessels are lacking in support,” says Dr. Saardi. “Some people have try vitamin K ointment to help with bruising after dermatological procedures. There have been some studies that a compound in vitamin K ointment can resolve bruising a little more quickly.”

There are also cosmetic applications available to help you cover up bruises. While these won’t treat the problem, they can boost your confidence if your bruises would otherwise be exposed.

“Some people find it easiest to cover them up cosmetically,” says Dr. Saardi. “The foundation that I like the most for skin problems in which the color of the problem is very different from the skin around it is DermaBlend. You can actually get fitted for the color to match your skin tone at a lot of beauty stores and it’s a very thick foundation that blocks a lot of light — it’s a very good cover-up for bruising and other skin discoloration.”

And of course, you may decide not to cover up your bruises at all — which is perfectly okay, too. What matters is that you feel good in your own skin (and that the bruises are not due to a serious medical issue that requires treatment or a medication change).

“I started to think about the bruises as part of the process of finding an effective treatment,” says Leach. “In the end, I sort of embraced the bruising as a visible sign of an illness that is so often invisible. If someone asked me how I got a bruise, it gave me the opportunity to teach them about the reality of life with rheumatoid arthritis.”

Track Your Symptoms with ArthritisPower

Join CreakyJoints’ patient-centered research registry and track symptoms like fatigue and pain. Sign up.

Do You Bruise Easily? When to Get It Checked Out. Cleveland Clinic. March 9, 2020. https://health.clevelandclinic.org/do-you-bruise-easily-when-to-get-it-checked/.

Drug-induced thrombocytopenia. U.S. National Library of Medicine. May 22, 2019. https://medlineplus.gov/ency/article/000556.htm.

Interview with Jiha Lee, MD, a Clinical Assistant Professor at Michigan Medicine

Interview with Karl Saardi, MD, a dermatologist at The GW Medical Faculty Associates

Interview with Mariah Leach, founder of Mamas Facing Forward, a website and support group for moms living with chronic illness

Jouglas KMJ, et al. Cutaneous abnormalities in rheumatoid arthritis compared with non‐inflammatory rheumatic conditions. Annals of the Rheumatic Diseases. February 13, 2006. doi: https://doi.org/10.1136/ard.2005.048934.

Methotrexate (oral). Michigan Medicine. July 28, 2020. https://www.uofmhealth.org/health-library/d00060a1.

Niculet E, et al. Glucocorticoid-Induced Skin Atrophy: The Old and the New. Clinical, Cosmetic and Investigational Dermatology. December 30, 2020. https://doi.org/10.2147/CCID.S224211.

Pasadyn SR, et al. Cutaneous adverse effects of biologic medications. Cleveland Clinic Journal of Medicine. May 2020. doi: https://doi.org/10.3949/ccjm.87a.19119.

Rheumatoid Vasculitis. Johns Hopkins Vasculitis Center. Accessed September 27, 2021. https://www.hopkinsvasculitis.org/types-vasculitis/rheumatoid-vasculitis/.

Rheumatoid Vasculitis. Cedars-Sinai. Accessed September 27, 2021. https://www.cedars-sinai.org/health-library/diseases-and-conditions/r/rheumatoid-vasculitis.html.

Thrombocytopenia (low platelet count). Mayo Clinic. April 8, 2020. https://www.mayoclinic.org/diseases-conditions/thrombocytopenia/symptoms-causes/syc-20378293.

Ting P, et al. Atrophic patches. Canadian Family Physician. December 10, 2006. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1783752/.