Hematidrosis

Hematidrosis also called hematohidrosis or hemidrosis, is a rare skin disease in which blood oozes from the sweat glands periodically ¹. Hematidrosis is a condition in which blood vessel capillaries that feeds the sweat glands rupture, causing them to exude blood, and occurs under conditions of extreme physical or emotional stress. One author proposed the term “hematofolliculohidrosis” because it appeared along with sweat-like fluid and blood exudes via the follicular canals ². Hematidrosis signs and symptoms include sweating blood, crying bloody tears, bleeding from the nose, bleeding from the ears, or oozing blood from other skin surfaces. The episodes are usually self-limiting. In some cases, the fluid appears to be blood tinged, while others resemble frank blood. It can occur on any part of the body, but most commonly appears on the face (ear, nose, and eyes).

The cause of hematidrosis is unknown. The bleeding is due to the rupture of the very small blood vessels of the skin (dermal capillaries) ³. Hematidrosis may occur when a person is suffering extreme levels of stress, for example, facing his or her own death ³. Some theories include increased vascular pressure leading to the passage of blood cells through the ducts of the sweat glands, inflammation of the vessels of the skin (vasculitis of dermal vessels), and intensified sympathetic activation ⁴. Some cases are associated with systemic disease, bleeding disorders, menstruation, excessive exertion, high blood pressure, fear and intense emotional stress ⁵. Treatment remains a challenge, and may include vitamin C, hemostatic drugs, anxiolytics, or antidepressants, and propranolol ³. Resolution of symptoms may occur spontaneously ³.

Figure 1. Hematidrosis cases

Footnote: Unilateral hematohidrosis of left facial side observed on two separate occasions.

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Hematidrosis causes

The cause of hematidrosis is unknown. The bleeding is due to the rupture of the very small blood vessels of the skin (dermal capillaries) ³. Various causative factors, like it being component of systemic disease, vicarious menstruation, excessive exertion, psychogenic, psychogenic purpura and unknown causes have been suggested ⁷ Acute fear and intense mental contemplation are the most frequent causes, as reported in six cases in men condemned to execution, a case occurring during the London Blitz, a case involving fear of being raped, a case of fear of a storm while sailing, etc ². Hematidrosis has been reported with primary thrombocytopenic purpura ⁸. In another study, a case of hematidrosis, accompanied with otorrhea and otoerythrosis, has been reported ⁹. Hematohidrosis has also been reported in an 8-year-old child just as in this case without any specific pathology ¹⁰. In an Indian case report, the probable cause for hematohidrosis was chronic stress, as the other causes were ruled out by detailed investigations ¹¹. Hysterical mechanisms and psychosomatic disorders are also believed to induce bleeding ². Psychogenic purpura is supposed to be caused by hypersensitivity to the patients′ own blood or autoerythrocyte sensitization and is characterized by repeated crops of ecchymoses, gastrointestinal bleedings and hematuria.

Another type of bleeding through skin is psychogenic stigmata; a term used to signify areas of scars, open wounds or bleeding through the unbroken skin ¹². Patients belonging to this group were found to be frequently neurotic. The clinical findings of this type are a slight elevation of skin before prolonged oozing of blood, a pea-sized bluish discoloration on patient’s palm and erysipelas-like lesions. In another study, a patient developed bleeding from her old scars whenever she had severe anxiety ².

The extravasated blood has identical cell components as of peripheral blood. The severe mental anxiety activates the sympathetic nervous system to invoke the stress-fight or flight reaction to such a degree as to cause hemorrhage of the vessels supplying the sweat glands into the ducts of the sweat glands. Effect on the body is weakness and mild to moderate dehydration from the severe anxiety and both blood and sweat loss ¹³.

It has recently been proposed that there may be some defects in the dermis causing stromal weakness. These defects will communicate with vascular spaces in the dermis and they will eventually dilate and enlarge as blood-filled spaces when the blood comes in. After that, they will exude the blood out by either via follicular canals or directly on to the skin surface and this will occur whenever the positive pressure inside is enough. Later they will collapse leaving no scar. This phenomenon acts like a balloon, waxes and wanes and thus explains why these bleeding episodes are sometimes intermittent and self-limiting. Immediate biopsy is important because a biopsy done after these spaces collapse will not help in identifying them ². One study revealed some intradermal bleeding and emphraxised (obstructed) capillaries. No abnormality was found in sweat glands, hair follicles and sebaceous glands. They concluded that pathological basis for hematohidrosis might be a distinctive vasculitis ¹³.

Hematidrosis symptoms

Hematidrosis signs and symptoms include sweating blood, crying bloody tears, bleeding from the nose, bleeding from the ears, or oozing blood from other skin surfaces. The majority of the cases of hematidrosis had spontaneous episodes of bleeding, from various locations of the body, but mostly concentrating on the facial regions (e.g., ear, nose, and eyes); no apparent cause could be identified although some were stress induced, no specific therapy was deemed appropriate, and resolution of symptoms occurred spontaneously.

Hematidrosis treatment

At present, no specific treatment is available for hematidrosis. Treatment remains a challenge, and may include vitamin C, hemostatic drugs, anxiolytics, or antidepressants, and propranolol ³. Resolution of symptoms may occur spontaneously ³.

References

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2. Manonukul J, Wisuthsarewong W, Chantorn R, Vongirad A, Omeapinyan P. Hematidrosis: A pathologic process or stigmata. A case report with comprehensive histopathologic and immunoperoxidase studies. Am J Dermatopathol. 2008;30:135–9.
3. Jafar A, & Ahmad A. Child Who Presented with Facial Hematohidrosis Compared with Published Cases. CaseReports in Dermatological Medicine. 781.. 2016; 2016:5095781. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4808663
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8. Duan Y, Zhao X, Xu X, Yang J, Li Z. Treatment of Primary Thrombocytopenic purpura by Modified Minor Decoction of bupleurum. J Tradit Chin Med. 1995;15:96–8.
9. Migliorini L. Hematidrosis otorrhea with otoerythrosis. Friuli Med. 1962;17:768–74.
10. Dubeikovskaia EG. Hematohidrosis in an 8 year old child. Pediatriia. 1959;37:70–3.
11. Jerajani HR, Jaju B, Phiske MM, Lade N. Hematohidrosis – a rare clinical phenomenon. Indian J Dermatol. 2009;54(3):290–292. doi:10.4103/0019-5154.55645 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2810702
12. Patel RM, Mahajan S. Hematohidrosis: A rare clinical entity. Indian Dermatol Online J. 2010;1(1):30–32. doi:10.4103/2229-5178.73256 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481423
13. Zhang FK, Zheng YL, Liu JH, Chen HS, Liu SH, Xu MQ, et al. Clinical and laboratory study of a case of hematidrosis. Zhonghua Xue Ye Xue Za Zhi. 2004;25:147–50.