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Mozafari N, Farjami M, Jamali E, Rostami H, Ketabi Y. Acute localized exanthematous pustulosis caused by enoxaparin. Clin Exp Dermatol 2021; 46:1607-1609. [PMID: 34192360 DOI: 10.1111/ced.14805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 12/01/2022]
Abstract
Notably, enoxaparin has not been described to cause acute localized exanthematous pustulosis (ALEP). Herein, we present a case of a woman with a cutaneous drug reaction consistent with ALEP that occurred after enoxaparin. This case highlights enoxaprin as a novel causative agent for this type of drug reaction.
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Affiliation(s)
- N Mozafari
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Departments of Dermatology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Farjami
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - E Jamali
- Department of Pathology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - H Rostami
- Departments of Dermatology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Y Ketabi
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Identifying the Culprit Drug in Severe Cutaneous Adverse Reactions (SCARs). CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00291-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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3
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Assier H, Gener G, Chosidow O, Wolkenstein P, Ingen-Housz-Oro S. Acute generalized exanthematous pustulosis induced by enoxaparin: 2 cases. Contact Dermatitis 2020; 84:280-282. [PMID: 33131094 DOI: 10.1111/cod.13734] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Haudrey Assier
- Department of Dermatology, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, AP-HP, Hôpital Henri-Mondor, UPEC, Créteil, France
| | - Gwendeline Gener
- Department of Dermatology, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, AP-HP, Hôpital Henri-Mondor, UPEC, Créteil, France
| | - Olivier Chosidow
- Department of Dermatology, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, AP-HP, Hôpital Henri-Mondor, UPEC, Créteil, France
| | - Pierre Wolkenstein
- Department of Dermatology, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, AP-HP, Hôpital Henri-Mondor, UPEC, Créteil, France
| | - Saskia Ingen-Housz-Oro
- Department of Dermatology, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, AP-HP, Hôpital Henri-Mondor, UPEC, Créteil, France
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Osché M, Gusdorf L, Cribier B, Scrivener JN. Pustulose exanthématique aiguë localisée après injections d’héparine calcique. Ann Dermatol Venereol 2020; 147:207-211. [DOI: 10.1016/j.annder.2019.09.607] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/14/2019] [Accepted: 09/05/2019] [Indexed: 11/29/2022]
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Schindewolf M, Recke A, Zillikens D, Lindhoff-Last E, Ludwig RJ. Nadroparin carries a potentially high risk of inducing cutaneous delayed-type hypersensitivity responses. Contact Dermatitis 2017; 77:35-41. [DOI: 10.1111/cod.12764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/09/2016] [Accepted: 12/21/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Marc Schindewolf
- Division of Haemostaseology, Department of Internal Medicine; Goethe University Hospital; 60590 Frankfurt am Main Germany
- Division of Vascular Medicine, Swiss Cardiovascular Centre; University Hospital Bern; 3010 Bern Switzerland
| | - Andreas Recke
- Department of Dermatology and Lübeck Institute of Experimental Dermatology; University of Lübeck; 23538 Lübeck Germany
| | - Detlef Zillikens
- Department of Dermatology and Lübeck Institute of Experimental Dermatology; University of Lübeck; 23538 Lübeck Germany
| | - Edelgard Lindhoff-Last
- Division of Haemostaseology, Department of Internal Medicine; Goethe University Hospital; 60590 Frankfurt am Main Germany
- Agaplesion Bethanien Hospital, Cardiovascular Centre Bethanien (CCB); 60389 Frankfurt am Main Germany
| | - Ralf J. Ludwig
- Department of Dermatology and Lübeck Institute of Experimental Dermatology; University of Lübeck; 23538 Lübeck Germany
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Low-Molecular-Weight Heparins as Immunomodulators in Dermatology Practice. Am J Ther 2015; 23:e1911-e1917. [PMID: 25853237 DOI: 10.1097/mjt.0000000000000251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Low-molecular-weight heparins (LMWHs) have some effects on cell proliferation and inflammation beyond mere anticoagulation. They have been tried on treatment of a few dermatological disorders such as lichen planus, skin wound healing, recurrent aphtous stomatitis, chronic urticaria, and contact hypersensitivity. LMWHs are generally well-tolerated drugs, rarely can lead to severe reactions. In this article, we will review the novel indications of LMWHs in dermatology practice and common skin reactions associated with their use.
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Ivanova I, Marco Segarra E, Agusti Corredor J, Pagés Reverter J. Reacción de hipersensibilidad retardada por enoxaparina sódica subcutánea. Semergen 2013; 39:59-60. [DOI: 10.1016/j.semerg.2012.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 07/29/2012] [Accepted: 07/30/2012] [Indexed: 10/27/2022]
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Abstract
Heparins are widely used for prophylaxis and treatment of thromboembolic diseases. Besides bleeding complications, heparin-induced skin lesions are the most frequent unwanted adverse effects of subcutaneous heparin treatment. Evidence suggests that these lesions are more common than previously thought. Lesions are most frequently due to either allergic reactions or to possibly life-threatening heparin-induced thrombocytopenia. Early recognition and adequate treatment are highly important, because although both complications initially show a similar clinical picture, their treatment should be fundamentally different. Furthermore, risk factors associated with the patient, drug, and treatment regimen have been identified. We review the clinical range of heparin-induced skin lesions, emphasise evidence and controversies in epidemiology, diagnosis, and differential diagnosis, and discuss the management of patients with these skin lesions.
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Affiliation(s)
- Marc Schindewolf
- Division of Vascular Medicine and Haemostaseology, Department of Internal Medicine, Hospital of the Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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Abstract
Low-molecular-weight heparins are widely used for the prophylaxis and treatment of venous thromboembolism. However, they can induce adverse skin reactions. The most common reactions are delayed-type hypersensitivity reactions at injection sites. Rare systemic reactions have been reported. We report, to our knowledge, the first case of a drug reaction with eosinophilia and systemic symptoms syndrome (DRESS) due to enoxaparin which belongs to the low-molecular-weight heparins class.
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Affiliation(s)
- Sophie Ronceray
- Department of Dermatology, Pontchaillou University Hospital, Rennes, France
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Maldonado Cid P, Alonso de Celada RM, Noguera Morel L, Feito-Rodríguez M, Gómez-Fernández C, Herranz Pinto P. Cutaneous adverse events associated with heparin. Clin Exp Dermatol 2012; 37:707-11. [DOI: 10.1111/j.1365-2230.2012.04395.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
All the adverse effects of heparins are related to their wide variety of biological activities, with bleeding being the most important safety issue, resulting directly from the potency of heparin as an anticoagulant. However, it is hard to define the bleeding risk, since it depends on numerous parameters including the indication, dosage, method, and duration of heparin application, the clinical study design and definition of bleeding as well as patient characteristics and determinants of bleeding such as type of surgery and co-medication. Nonbleeding complications of heparins are caused by binding of heparin molecules to proteins other than antithrombin and to cells, which is generally more pronounced with unfractionated heparin than with low-molecular-weight heparins. Accordingly, heparin-induced thrombocytopenia, the most severe nonbleeding adverse reaction, occurs about 10 times less with low-molecular-weight heparins than with unfractionated heparin. Frequent and therefore important adverse reactions of heparins are skin lesions resulting from delayed-type hypersensitivity reactions. All the other undesirable effects are discussed as well, but they are mostly clinically irrelevant.
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Affiliation(s)
- S Alban
- Pharmazeutisches Institut, Abteilung Pharmazeutische Biologie, Christian-Albrechts-Universität zu Kiel, Kiel, Germany.
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Weberschock T, Meister AC, Bohrt K, Schmitt J, Boehncke WH, Ludwig RJ. The risk for cross-reactions after a cutaneous delayed-type hypersensitivity reaction to heparin preparations is independent of their molecular weight: a systematic review. Contact Dermatitis 2011; 65:187-94. [DOI: 10.1111/j.1600-0536.2011.01932.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Scherer K, Tsakiris DA, Bircher AJ. Überempfindlichkeits- und allergische Reaktionen auf hämostaseologisch wirksame Medikamente. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Schindewolf M, Schwaner S, Wolter M, Kroll H, Recke A, Kaufmann R, Boehncke WH, Lindhoff-Last E, Ludwig RJ. Incidence and causes of heparin-induced skin lesions. CMAJ 2009; 181:477-81. [PMID: 19786468 DOI: 10.1503/cmaj.081729] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Little is known about the incidence and causes of heparin-induced skin lesions. The 2 most commonly reported causes of heparin-induced skin lesions are immune-mediated heparin-induced thrombocytopenia and delayed-type hypersensitivity reactions. METHODS We prospectively examined consecutive patients who received subcutaneous heparin (most often enoxaparin or nadroparin) for the presence of heparin-induced skin lesions. If such lesions were identified, we performed a skin biopsy, platelet count measurements, and antiplatelet-factor 4 antibody and allergy testing. RESULTS We enrolled 320 patients. In total, 24 patients (7.5%, 95% confidence interval [CI] 4.7%-10.6%) had heparin-induced skin lesions. Delayed-type hypersensitivity reactions were identified as the cause in all 24 patients. One patient with histopathologic evidence of delayed-type hypersensitivity tested positive for antiplatelet-factor 4 antibodies. We identified the following risk factors for heparin-induced skin lesions: a body mass index greater than 25 (odds ratio [OR] 4.6, 95% CI 1.7-15.3), duration of heparin therapy longer than 9 days (OR 5.9, 95% CI 1.9-26.3) and female sex (OR 3.0, 95% CI 1.1-8.8). INTERPRETATION Heparin-induced skin lesions are relatively common, have identifiable risk factors and are commonly caused by a delayed-type hypersensitivity reaction (type IV allergic response).
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Affiliation(s)
- Marc Schindewolf
- Department of Internal Medicine, Division of Angiology, Hospital of the Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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Bassas P, Bartralot R, García-Patos V. Anticoagulation and Antiplatelet Therapy in Dermatology. ACTAS DERMO-SIFILIOGRAFICAS 2009. [DOI: 10.1016/s1578-2190(09)70004-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Bilac DB, Ermertcan AT, Ozturkcan S, Sahin MT, Temiz P. Acute generalized exanthematous pustulosis (AGEP) due to exposure to sulfuric acid and bromic acid vapor: a case report. Cutan Ocul Toxicol 2008; 27:117-21. [PMID: 18568897 DOI: 10.1080/15569520802060416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Acute generalized exanthematous pustulosis (AGEP, toxic pustuloderma, pustular drug eruption) is a not uncommon cutaneous reaction pattern that is usually related to drug administration. The eruption is of sudden onset and appears 7-10 days after the medication is started. A 22-year-old male patient who was a student at a chemical faculty attended our outpatient clinic with a complaint of pustular eruption on his face. According to his history, the eruption started with pruritus and erythema on his chin 3 days ago and spread to his face and chest. He explained that he had performed an experiment with sulfuric acid and bromic acid and was exposed to their vapor. His dermatological examination revealed erythema and pustules on his cheeks, on his chin, above his upper lip, and on his eyebrows. He also had a few pustules on his chest. There were no ocular, mucous membrane, or pulmonary symptoms. Histopathological examination of the skin biopsy specimen revealed superficial orthokeratosis, focal subcorneal pustule formation, and perivascular chronic inflammatory cell infiltration in superficial dermis. After administration of systemic antihistamines and wet dressing topically, we observed rapid healing of the lesions. Because there was no systemic drug intake in his history, we were concerned that exposure to sulfuric acid and bromic acid vapor caused AGEP in this patient. We present this rare case to show that the vapor of chemical materials may cause AGEP or other drug eruptions.
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Affiliation(s)
- Dilek Bayraktar Bilac
- Department of Dermatology, Medical Faculty of Celal Bayar University, Manisa, Turkey.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2008. [DOI: 10.1002/pds.1486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Gómez-Outes A, Gómez de la Bárcena C, Martínez-González J. Delayed-type hypersensitivity to low molecular weight heparins and heparinoids: cross-reactivity does not depend on molecular weight. Commentary. Br J Dermatol 2008; 158:869-70. [DOI: 10.1111/j.1365-2133.2008.08453.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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