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LETTER TO THE EDITOR

Increased Propensity to Bruising in Red-Haired Females: A Possible Role for von Willebrand Factor?

Department of Haematology; ICPMR, Westmead Hospital; Westmead, Australia; emmanuel{at}icpmr.wsahs.nsw.gov.au

To the Editor:

Liem et al. (1) studied the risk of bruising in women with red hair compared to those with black or brown hair, in response to anecdotal reports of increased perioperative bruising in redheads. They found a slightly increased risk of bruising, but there were no statistically significant differences between redheads and women with dark hair. However, one assay, high dose (i.e., 1.5 mg/mL) ristocetin induced platelet agglutination (RIPA), showed a difference that nearly reached statistical difference, with P = 0.06. This RIPA assay is dependent on the plasma and platelet level and activity of von Willebrand factor (vWF).

Congenital von Willebrands disease is the most common inherited bleeding disorder (2,3). Reduced levels or function of plasma vWF causes bleeding symptoms including bruising, postoperative bleeding, nose and gum bleeds, and menorrhagia. Genetic determinants other than the vWF gene may alter plasma vWF. For example, patients with Type O blood have significantly lower levels of plasma vWF than patients with other blood types (4,5). Similarly, Miller et al. (5,6) and others (7) have reported that African-American women show elevated levels and function of vWF compared with Caucasian women.

This raises several questions. On one level, and specifically for Liem et al. (1), could the differences in high-dose RIPA responsiveness identified in women with red hair be a result of reduced plasma vWF? On another level, should vWF be responsible, are the studies of Liem et al. (1) and others (5–7) pointing to another epigenetic phenomenon additional to ABO-blood group? Although entirely speculative, I can propose two avenues for future research, and specifically the investigation of the possible role of: (a) melanin or its various forms (eumelanin, which is brown, and phaeomelanin, which is red) and/or the melanocortin 1 receptor (responsible for the production of red hair in humans (8); and given that red-heads are often pale skinned); and (b) keratin and/or factors controlling keratin structure and/or associated genetic determinants (since keratin, which gives hair its structure, is also comprised, like vWF, of poly-protein subunits linked by cys-cys bonds (9), and the control of keratin structure may have some analogy to the control of plasma vWF structure and function.)

Footnotes

Dr. Sessler does not wish to respond.

REFERENCES

1. Liem EB, Hollensead SC, Joiner TV, Sessler DI. Women with red hair report a slightly increased rate of bruising but have normal coagulation tests. Anesth Analg 2006;102:313–18.[Abstract/Free Full Text]
2. Sadler JE, Mannucci PM, Berntorp E, et al. Impact, diagnosis and treatment of von Willebrand Diseaseqq. Thromb Haemost 2000;84:160–74.[Web of Science][Medline]
3. Favaloro EJ. Appropriate laboratory assessment as a critical facet in the proper diagnosis and sub-classification of von Willebrand’s disorder. Bailliere’s Best Pract Res Clin Haematol 2001;14:299–319.[Medline]
4. Favaloro EJ, Soltani S, McDonald J, et al. Reassessment of ABO-blood group, gender and age on laboratory parameters used to diagnose von Willebrand Disorder (VWD): potential influence on the diagnosis versus the potential association with risk of thrombosis. Am J Clin Pathol 2005;124:910–7.[Web of Science][Medline]
5. Miller CH, Haff E, Platt P, et al. Measurement of von Willebrand factor activity: relative effects of ABO blood type and race. J Thromb Haemostas 3002;1:2191–7.
6. Miller CH, Dilley A, Richardson L, et al. Population differences in von Willebrand factor levels affect the diagnosis of von Willebrand disease in African-American women. Am J Hematol 2001;67:125–9.[Web of Science][Medline]
7. Sukhu K, Poovalingam V, Mahomed R, Giangrande PLF. Ethnic variation in von Willebrand factor levels can influence the diagnosis of von Willebrand disease. Clin Lab Haematol 2003;25:247–9.[Web of Science][Medline]
8. Rees JL. The Melanocortin 1 receptor (MC1R): more than just red hair. Pigment Cell Res 2000;13:135–40.[Web of Science][Medline]
9. Harrison S, Sinclair R, Hair colouring, permanent styling and hair structure. J Cosmetic Dermatol 2004;2:180–5.

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