A hickey, medically referred to as traumatic purpura or superficial ecchymosis, is a localized bruise caused by intense suction or pressure on the skin. This forceful action ruptures small capillaries, allowing blood to leak out and pool beneath the skin, resulting in a red, purple, or dark blue mark that typically fades within two weeks. Many other conditions and accidental occurrences can produce a similar-looking mark with a different origin. Differentiating between a benign, externally-caused mark and a spot signaling an internal health issue is the primary concern.
Marks Caused by Accidental Pressure and Friction
The most common mimics of a hickey are simple bruises or collections of petechiae—tiny, pinpoint hemorrhages—caused by forgotten mechanical trauma. These marks appear when physical force damages capillaries, similar to a hickey, but without deliberate suction. A frequent culprit is restrictive clothing, such as a tightly cinched backpack strap, a bra underwire, or a stiff collar that rubs against the skin.
Pressure marks often appear where skin is thin or close to a bony prominence, making the capillaries more vulnerable to rupture. Minor bumps against furniture are often overlooked by the time the bruise becomes visible. Sleeping posture can also cause discoloration if the skin is pressed against a firm surface for an extended period, particularly in individuals with fragile vessels. This accidental trauma usually results in a single, isolated mark that follows the typical color progression of a bruise, fading from red to blue-purple, then greenish-yellow as the body reabsorbs the blood.
Dermatological and Vascular Skin Lesions
Certain benign skin conditions can produce permanent or semi-permanent spots frequently mistaken for old hickeys or bruises due to their dark red or purple coloration. Cherry angiomas are common, small, bright-red or purplish spots made up of clusters of dilated blood vessels. These harmless, dome-shaped lesions often appear on the torso and limbs, especially after age 30, but their vivid color can lead to misidentification.
Petechiae are another common presentation, appearing as flat, tiny, red-purple dots less than three millimeters in diameter. While they can signal systemic issues, petechiae also result from localized, benign causes like intense vomiting, a severe coughing fit, or prolonged straining, which temporarily increases pressure in the capillaries of the face, neck, and chest. Unlike a bruise, petechiae and purpura (lesions between three millimeters and one centimeter) do not blanch, or turn white, when pressed. Telangiectasias, commonly known as spider veins, are small, dilated blood vessels close to the skin surface; a cluster of these can create a localized red or purple patch resembling an old, fading bruise.
Indicators of Systemic Health Concerns
When bruising or purpura appears easily, frequently, or without known injury, it can signal an underlying systemic condition affecting the blood’s ability to clot or the fragility of blood vessels. Certain medications increase the tendency to bruise, particularly blood thinners like warfarin, antiplatelet drugs, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and aspirin. Long-term use of corticosteroids, which thin the skin, also contributes to easier bruising.
Nutritional deficiencies can compromise the integrity of blood vessels, making them prone to leaking blood. A lack of Vitamin C (necessary for collagen production) or Vitamin K (essential for blood clotting factors) can manifest as purpura or ecchymosis.
More serious possibilities involve disorders affecting platelets or coagulation factors. Low platelet counts (thrombocytopenia) or inherited clotting disorders like von Willebrand disease often lead to frequent, unexplained bruising.
Widespread or unusual purpura can also be a sign of vasculitis (inflammation of the blood vessels) or a severe infection like sepsis, where clusters of tiny blood spots may appear. These manifestations require immediate medical evaluation because they reflect a serious internal process. Older adults commonly experience senile purpura, where chronic sun damage and age-related loss of collagen cause blood vessels to become brittle, resulting in dark, irregular patches, usually on the forearms.
When to Consult a Healthcare Professional
While most hickey mimics are benign and self-resolving, medical attention is necessary if a spot is accompanied by “red flag” symptoms. Consult a doctor if the marks are painful, rapidly spreading, or appear without explanation in unusual locations like the back, torso, or face. Any purpuric spots that do not fade or resolve after two weeks warrant professional evaluation, as prolonged discoloration can indicate an issue with blood reabsorption.
Urgent care is important if the marks are accompanied by systemic symptoms, such as a high fever, severe headache, joint pain, nausea, or unexplained fatigue. Unexplained bruising combined with other signs of abnormal bleeding, like frequent nosebleeds, blood in the urine or stool, or bleeding into the joints, suggests a possible clotting disorder requiring prompt diagnosis and management. If you are taking medication that affects clotting, or if the mark appears as part of a sudden, widespread rash, professional evaluation is the safest course of action.