The mysterious Trump hand stains

Periodically, a photo of Donald Trump shaking hands goes viral, and people zoom in on what appears to be a stain on the back of one hand: a pale, oddly textured patch that doesn’t quite match the surrounding skin, or a dark purple-blue mark that looks like a bruise (Figure 1). Internet sleuths have offered theories ranging from ink stains to secret health crises. Recent disclosures from Trump’s medical team and Trump himself have only muddied the waters. There may be a combination of factors contributing to the "stains". 

First one should distinguish between two types of stains/marks:

• The "Stains": (Makeup over Bruising): In recent photos, the backs of Trump's hands appear to have patchy, uneven skin tones. According to Reuters and White House statements, these are not stains in the traditional sense. They are patches of foundation or concealer. Trump has reportedly used makeup to cover large, dark bruises (ecchymosis) on his hands to make them less apparent during public appearances.
• The "Red Marks": Earlier photos from 2024 showed bright red splotches. Dermatologists speculated these were likely nonspecific rashes, irritation from excessive handwashing (driven by Trump’s known germophobia), blisters caused by friction from golf clubs, or perhaps an unusual bruise.

Trump and the White House medical team have offered varied explanations. One is minor soft-tissue irritation/trauma from frequent handshaking. A second is Trump has been diagnosed with chronic venous insufficiency after evaluation for leg swelling, but this condition affects the legs and shouldn't cause bruises on the hands. Then there is the admission by Trump himself that he takes high daily levels of aspirin that can make him more prone to bruising because of aspirin's anticoagulant properties.

Exploring the possibilities, one can place them into four categories:

1. "Just bruises" + camera amplification.  Hands get bumped, squeezed, and grabbed constantly. The back of the hand has thin soft tissue, so even minor trauma can look dramatic, especially under harsh lighting and when photographed repeatedly.
2. Age-related “actinic purpura.” There’s a very common, benign phenomenon in which older adults develop large, flat purple bruises on the forearms and backs of the hands after minor trauma, because the skin and connective tissue become more fragile.
3. Medication effects (aspirin is a prime suspect). Medications that affect clotting can make ordinary bumps turn into showy bruises. Aspirin is the classic example.
4. A skin issue (for the “red marks” photos). Red spots are a different visual story than a bruise or concealer patch. Dermatitis/irritation from dryness, handwashing, friction, minor burns, or other nonspecific rashes are all plausible categories.

As an etymological aside, the term actinic purpura, also known as senile purpura or solar purpura, is a common, benign skin condition affecting older adults and characterized by the appearance of persistent, dark purple bruise-like patches (ecchymoses) on the skin. The word "actinic" refers to conditions caused by light or radiation and in particular ultraviolet (UV) sunlight. "Purpura" is the Latin word for purple, and so "actinic purpura" literally translates to "purple bruising caused by light rays." It affects a significant percentage of people over age 50 and becomes more common with advancing age. The use of blood thinners (like aspirin, warfarin, or clopidogrel) or systemic corticosteroids (like prednisone) can worsen the condition or make bruising happen more easily.

Recently, Trump confirmed in an interview that he has been taking a daily dose of 325 mg of aspirin for roughly 25 years. This is a significant detail. While many seniors take a "baby aspirin" (81 mg) for heart health, 325 mg is a full-strength dose. Donald Trump has stated he takes this high dose because he is "superstitious" about his heart health. 

Aspirin functions as a blood thinner by inhibiting platelets, the cells in your blood responsible for clotting. It irreversibly inhibits the enzyme cyclooxygenase-1 (COX-1) within platelets by attaching an acetyl group to a specific serine residue in the active site of COX-1, permanently disabling the enzyme. This inhibition blocks the conversion of arachidonic acid into prostaglandin H2, which is the necessary precursor for thromboxane A2, a potent agent that signals platelets to clump together and constrict blood vessels. In the absence of thromboxane A2, platelets cannot aggregate to form clots.

This anticoagulant property is why aspirin is widely prescribed to patients with cardiovascular risk, especially heart attacks and ischemic stroke. However, its use is typically for secondary prevention and not primary prevention. Secondary prevention is treating patients who have already suffered a heart attack, stroke, or have established coronary artery disease. In these cases, aspirin is a standard, lifelong therapy because the benefit of preventing a recurrent, potentially fatal event significantly outweighs the risk of bleeding. On the other hand, for primary prevention, preventing a first event in patients who have risk factors but no history of heart disease, guidelines have become more conservative. Most major health organizations now recommend against its routine use for primary prevention in adults over 60, reserving it only for select younger adults (ages 40–59) who have a high cardiovascular risk profile and a low bleeding risk. 

The bleeding risk encompasses gastrointestinal (GI) bleeding and ulcers, as well as the rare but dangerous hemorrhagic stroke. Easy bruising is a less concerning side effect. In addition, more aspirin can lead to increased bleeding risk without more protection from cardiovascular disease. In a large trial of patients with cardiovascular disease, the 81 mg (baby) daily dose had similar effectiveness to the larger 325 mg (adult) dose.

In summary, the most likely scenario is:

1. The visible "stains" are often makeup applied to cover bruising (Figure 1).
2. The bruising may arise from minor trauma (handshakes/golfing).
3. Actinic purpura can make hand bruises more likely and more dramatic.
4. Taking a daily high dose of aspirin can further promote easy bruising.

In other words, the combination of high-dose aspirin, the weakening skin of an almost 80-year-old man, and the physical toll of political handshaking creates bruises. The "stains" are simply the makeup applied to hide them.

Figure 1. The mysterious Trump hand stains appear to be makeup covering up large bruises (STAT, Andrew Caballero-Reynolds/AFP via Getty Images).