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Diong S, Clowry J, Wynne B. General dermatology and dermatology in primary healthcare. Clin Exp Dermatol 2024; 49:418-419. [PMID: 38123491 DOI: 10.1093/ced/llad454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023]
Abstract
Heparin-induced bullous haemorrhagic dermatosis is an uncommon cutaneous adverse reaction to heparin, thought to be under-reported owing to its relatively asymptomatic presentation and favourable prognosis. This vesiculobullous condition is largely self-limiting and tends to resolve spontaneously despite continued anticoagulant therapy. Correct identification can reassure clinicians and patients alike.
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Affiliation(s)
- Sophie Diong
- Dermatology Department, St James's Hospital Dublin Ireland, Dublin, Ireland
| | - Julianne Clowry
- Dermatology Department, St James's Hospital Dublin Ireland, Dublin, Ireland
| | - Bairbre Wynne
- Dermatology Department, St James's Hospital Dublin Ireland, Dublin, Ireland
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Rakotonandrasana F, Sendrasoa FA, Rakotomanana AMKA, Andriatahina HFP, Ralimalala VN, Ramily SL, Sata M, Raharolahy O, Andrianarison M, Ranaivo IM, Ramarozatovo LS, Rapelanoro Rabenja F. Bullous Hemorrhagic Dermatosis Induced by Enoxaparin: About a Case in Madagascar. Case Rep Dermatol Med 2023; 2023:5710870. [PMID: 37954538 PMCID: PMC10635747 DOI: 10.1155/2023/5710870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 10/01/2023] [Accepted: 10/27/2023] [Indexed: 11/14/2023] Open
Abstract
Bullous hemorrhagic dermatosis is an adverse reaction occurring within 5 to 21 days after anticoagulation; the diagnosis is to be evoked in the presence of hemorrhagic bullous lesions at a distance from the injection site in the days following the introduction of anticoagulant; this is a diagnosis of exclusion. It is a rare pathology that mainly affects the elderly. A 54-year-old man presented with bullous hemorrhagic lesions on the left upper limb starting at the 4th day after enoxaparin injection, diagnosed as a bullous hemorrhagic dermatosis induced by enoxaparin. We report the first case of bullous hemorrhagic dermatosis induced by enoxaparin in Madagascar.
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Affiliation(s)
| | | | | | | | | | - Samson Léophonte Ramily
- Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo 101, Madagascar
| | - Moril Sata
- Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo 101, Madagascar
| | - Onivola Raharolahy
- Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo 101, Madagascar
| | - Malalaniaina Andrianarison
- Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo 101, Madagascar
| | - Irina Mamisoa Ranaivo
- Department of Dermatology, Faculty of Medicine, University of Toamasina, Toamasina 501, Madagascar
| | - Lala Soavina Ramarozatovo
- Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo 101, Madagascar
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Lovatt CA, Ye WQW, Yousuf H. Dermatose bulleuse hémorragique probablement associée au fondaparinux. CMAJ 2021; 193:E1322-E1325. [PMID: 34426453 PMCID: PMC8412431 DOI: 10.1503/cmaj.202747-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Catherine Anne Lovatt
- Département de médecine (Lovatt, Ye, Yousuf), Faculté des sciences de la santé, Université McMaster; Hamilton Health Sciences (Yousuf), Hamilton, Ont
| | - Wen Qing Wendy Ye
- Département de médecine (Lovatt, Ye, Yousuf), Faculté des sciences de la santé, Université McMaster; Hamilton Health Sciences (Yousuf), Hamilton, Ont
| | - Haroon Yousuf
- Département de médecine (Lovatt, Ye, Yousuf), Faculté des sciences de la santé, Université McMaster; Hamilton Health Sciences (Yousuf), Hamilton, Ont.
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Cortez de Almeida RF, Vita Campos C, Daxbacher EL, Jeunon T. Heparin-Induced Bullous Hemorrhagic Dermatosis: A Report of an Exceptionally Exuberant Case and Literature Review. Am J Dermatopathol 2021; 43:497-505. [PMID: 33795557 DOI: 10.1097/dad.0000000000001787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Heparin-induced bullous hemorrhagic dermatosis (HBHD) is an unusual cutaneous adverse reaction to heparin characterized by acute onset of hemorrhagic bullae. METHODOLOGY An exuberant case of HBHD is reported, and a revision of previously reported cases indexed on PubMed is provided. Cases were tabulated to the following parameters: sex, age, type of heparin and route of administration, associated medical procedure, number of days between heparin start and onset of lesions, site of the lesions, level of blister on histopathology, inflammatory infiltrate on histopathology, direct immunofluorescence findings, heparin-related intervention, number of days to resolution of skin lesions, associated hemorrhagic event, and outcome. CASE REPORT A 21-year-old woman with end-stage renal disease was receiving intravenous unfractioned heparin (UFH) during hemodialysis section for the past 3 months. Four hours after using for the first time an arteriovenous fistula punctured on her right wrist, the patient noticed the onset of vesicles and blisters on the right forearm containing citrus or serohemorrhagic exudate, which became overt hemorrhagic in 24 hours. Histopathology depicted a nonacantholytic subcorneal blister containing erythrocytes and plasma without any significant dermal inflammatory infiltrate. RESULTS Sixty cases of HBHD were included. HBHD affected predominantly men, with a male/female rate of 2.75. The age range was from 21 to 94 years, with an average of 70.8 and a median of 72 years. Nine patients used UFH, and 54 patients used low molecular weight heparins (3 patients used both). The lapse of time between the start of heparin and the onset of skin lesion varied from 6 hours to 240 days, with an average of 17.3 days and a median of 7 days. Limbs were affected in most of the cases. The level of the blister was subcorneal in 10 patients, intraepidermal in 30, subepidermal in 8, and both intraepidermal and subepidermal in 1. In 33 cases, there was no significant dermal inflammatory infiltrate. Pure lymphocytic inflammatory infiltrate was present in 10 cases. Eosinophils were found within the dermal inflammatory infiltrate in 2 cases, neutrophils in 2, and a mixture of eosinophils and neutrophils in other 2. Direct immunofluorescence was performed in 18 cases, all of them with negative results. DISCUSSION We hypothesize that mechanical trauma, skin fragility, and the anticoagulation effect of heparin might contribute concomitantly to the development of the lesions and speculate that subepidermal blisters in HBHD could be formed by rupture of the floor of a former intraepidermal blister.
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Affiliation(s)
| | - Clarissa Vita Campos
- Dermatology Department, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil ; and
| | - Egon Luiz Daxbacher
- Dermatology Department, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil ; and
| | - Thiago Jeunon
- Dermatology Department, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil ; and
- ID- Investigação em Dermatologia, Rio de Janeiro, Brazil
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Martin MU, Lambert A, Miremont G, Gaiffe A, Agier MS, Studer M, Mahé A, Tebacher M, Cribier B. Bullous haemorrhagic dermatitis induced by heparins and other anticoagulants: 94 cases from French pharmacovigilance centres and a literature review. Ann Dermatol Venereol 2021; 149:45-50. [PMID: 34175142 DOI: 10.1016/j.annder.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/17/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Bullous haemorrhagic dermatitis (BHD) is an uncommon and highly particular side effect of various forms of heparins. METHODS To better characterise the disease, we collected all cases from French Pharmacovigilance centres recorded over a 20-year period (37 cases) and performed a Medline literature search up to June 2020 (57 cases). RESULTS In all, 94 patients were identified (male/female ratio: 2.2) of mean age 73.5±12.1 years (31-94). Patients were treated with enoxaparin (n=66), unfractionated heparin (n=11), fondaparinux (n=10), tinzaparin (n=4), bemiparin (n=1), reviparin (n=1), dalteparin (n=1), and 4 with other anticoagulants: warfarin (n=3) and rivaroxaban (n=1). All cases presented with 1 to more than 100 haemorrhagic vesicles and bullae, distant from the injection sites, located mainly on the lower (75%) or upper limbs (69%). The lesions were asymptomatic, except in 5 patients who had pruritic or painful lesions. The interval between treatment initiation and BHD ranged from 6 hours to 30 days (mean: 8.4±7 days). Biopsy (n=53) showed intraepidermal or subcorneal cavity with red cells (n=39) or junctional blisters (n=10), with eosinophilic infiltrate only rarely. Direct immuno-fluorescence was negative in 19/20 cases and indirect immunofluorescence was negative in 8/8. The outcome was favourable in all cases, including in 12 patients for whom heparin was maintained. A 93-year-old patient died of compressive haematomas unrelated to BHD. We found 5 cases similar to BHD due to other anticoagulants. DISCUSSION This is the largest comprehensive series of this adverse effect due to heparins or, more rarely, to other anticoagulants. Dermatologists must be aware of BHD, since this benign side effect does not necessarily require interruption of treatment. It is rare, considering the large-scale prescription of heparins, and occurs mainly in male patients aged over 70. Although the presentation is highly typical, the physiopathology is difficult to understand, as coagulation parameters are usually normal. Aging, skin fragility or mechanical factors might play a role.
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Affiliation(s)
- M-U Martin
- Centre régional de pharmacovigilance de Strasbourg, HUS, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - A Lambert
- Centre régional de pharmacovigilance de Strasbourg, HUS, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - G Miremont
- Pôle de santé publique, pharmacologie médicale, centre de pharmacovigilance de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - A Gaiffe
- Centre régional de pharmacovigilance de Besançon, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - M-S Agier
- Centre régional de pharmacovigilance de Tours, 2, boulevard Tonnellé, 37000 Tours, France
| | - M Studer
- Service de dermatologie, centre hospitalier de Colmar, 39, avenue de la Liberté, 68000 Colmar, France
| | - A Mahé
- Service de dermatologie, centre hospitalier de Colmar, 39, avenue de la Liberté, 68000 Colmar, France
| | - M Tebacher
- Centre régional de pharmacovigilance de Strasbourg, HUS, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - B Cribier
- Clinique dermatologique, hôpitaux universitaires et université de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France.
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Lovatt CA, Ye WQW, Yousuf H. Probable fondaparinux-associated bullous hemorrhagic dermatosis. CMAJ 2021; 193:E801-E804. [PMID: 34059496 PMCID: PMC8177931 DOI: 10.1503/cmaj.202747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Catherine Anne Lovatt
- Department of Medicine (Lovatt, Ye, Yousuf), Faculty of Health Sciences, McMaster University; Hamilton Health Sciences (Yousuf), Hamilton, Ont
| | - Wen Qing Wendy Ye
- Department of Medicine (Lovatt, Ye, Yousuf), Faculty of Health Sciences, McMaster University; Hamilton Health Sciences (Yousuf), Hamilton, Ont
| | - Haroon Yousuf
- Department of Medicine (Lovatt, Ye, Yousuf), Faculty of Health Sciences, McMaster University; Hamilton Health Sciences (Yousuf), Hamilton, Ont.
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Rodríguez-Villa Lario A, Piteiro-Bermejo AB, Bèa-Ardébol S. Enoxaparin-induced distal haemorrhagic bullous dermatosis. Rev Clin Esp 2021; 221:125-126. [PMID: 32317106 DOI: 10.1016/j.rce.2019.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 11/25/2022]
Affiliation(s)
- A Rodríguez-Villa Lario
- Servicio de Dermatología, Hospital Universitario Príncipe de Asturias, Meco, Madrid, España.
| | - A B Piteiro-Bermejo
- Servicio de Dermatología, Hospital Universitario Príncipe de Asturias, Meco, Madrid, España
| | - S Bèa-Ardébol
- Servicio de Dermatología, Hospital Universitario Ramón y Cajal, Madrid, España
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Rodríguez-Villa Lario A, Piteiro-Bermejo AB, Bèa-Ardébol S. Enoxaparin-induced distal haemorrhagic bullous dermatosis. Rev Clin Esp 2020; 221:125-126. [PMID: 33998488 DOI: 10.1016/j.rceng.2019.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | - A B Piteiro-Bermejo
- Servicio de Dermatología, Hospital Universitario Príncipe de Asturias, Meco, Madrid, Spain
| | - S Bèa-Ardébol
- Servicio de Dermatología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Frizzell MR, Nguyen NM, Goldberg LH, Parikh SA, Sinai MJ. Heparin-induced bullous hemorrhagic dermatosis: A report of 3 cases. JAAD Case Rep 2020; 6:1065-1068. [PMID: 33209970 PMCID: PMC7659429 DOI: 10.1016/j.jdcr.2020.06.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
| | - Nhan M. Nguyen
- Houston Methodist, Department of Dermatology, Houston, Texas
| | - Leonard H. Goldberg
- Houston Methodist, Department of Dermatology, Houston, Texas
- DermSurgery Associates, Houston, Texas
- Correspondence to: Leonard H. Goldberg, MD, DermSurgery Associates, 7515 S Main St, Ste 240, Houston, TX 77030.
| | - Sonal A. Parikh
- Houston Methodist, Department of Dermatology, Houston, Texas
| | - Maya J. Sinai
- Houston Methodist, Department of Dermatology, Houston, Texas
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Gérard A, Levavasseur M, Gaboriau L, Stichelbout M, Staumont-Salle D. [Hemorrhagic bullous dermatosis (HBD): A rare side-effect of heparins]. Ann Dermatol Venereol 2020; 147:446-450. [PMID: 32005507 DOI: 10.1016/j.annder.2019.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 02/04/2019] [Accepted: 08/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Bullous haemorrhagic dermatosis (BHD) induced by heparin is a rare and benign side effect of which we report two cases. PATIENTS AND METHODS Case 1: an 81-year-old man presented haemorrhagic bullae on the limbs and trunk 7 days after starting enoxaparin. The laboratory haemostasis assessment was normal. A diagnosis was made of BHD induced by enoxaparin and the patient's treatment was switched to apixaban, resulting in a favourable outcome with resolution of the lesions within 15 days. Case 2: a 71-year-old woman hospitalised for pulmonary embolism was given tinzaparin. At two months of treatment, haemorrhagic bullae were observed on her forearms at distance from the injection sites. A diagnosis of BHD induced by tinzaparin was made. Treatment with tinzaparin was continued and the lesions resolved within 15 days. DISCUSSION Heparin-induced BHD is a rare entity initially described in 2006. Ninety-five cases of heparin-induced BHD have been reported. It is characterized by multiple haemorrhagic bullae at a distance from the injection sites. Time to onset of lesions after heparin initiation ranges from 24h to 4 months. Laboratory assessment should be routinely performed to rule out any haemostasis disorders. Lesions subside within 15 days whether heparin is continued or withdrawn. CONCLUSION Heparin-induced BHD is a rare but benign side effect of heparins. In the absence of recommendations, therapeutic management should be adapted to the individual situation.
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Affiliation(s)
- A Gérard
- Service de dermatologie, hôpital Claude-Huriez, CHU de Lille, 59000 Lille, France; Université de Lille, 59000 Lille, France.
| | - M Levavasseur
- Service de dermatologie, hôpital Claude-Huriez, CHU de Lille, 59000 Lille, France; Université de Lille, 59000 Lille, France
| | - L Gaboriau
- Service de pharmacologie, CHU de Lille, Centre régional de pharmacovigilance, 59000 Lille, France
| | - M Stichelbout
- Laboratoire d'anatomie et de pathologie, centre de biopathologie, CHU de Lille, 59000 Lille, France
| | - D Staumont-Salle
- Service de dermatologie, hôpital Claude-Huriez, CHU de Lille, 59000 Lille, France; Université de Lille, 59000 Lille, France
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Heparin hemorrhagic bullae induced by enoxaparin. Med Clin (Barc) 2019; 156:42-43. [PMID: 31784110 DOI: 10.1016/j.medcli.2019.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/20/2019] [Accepted: 09/26/2019] [Indexed: 11/23/2022]
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Russo A, Curtis S, Balbuena-Merle R, Wadia R, Wong E, Chao HH. Bullous hemorrhagic dermatosis is an under-recognized side effect of full dose low-molecular weight heparin: a case report and review of the literature. Exp Hematol Oncol 2018; 7:15. [PMID: 29989046 PMCID: PMC6035443 DOI: 10.1186/s40164-018-0108-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 06/28/2018] [Indexed: 11/24/2022] Open
Abstract
Bullous hemorrhagic dermatosis (BHD) is a systemic side-effect of low molecular weight heparin, characterized by multiple intra-epidermal hemorrhages distant from the site of injection. There have been several small case series and literature reviews on BHD, but none have captured a complete set of reported patients. We sought to describe a case of BHD with late diagnosis and completely summarize the existing English and Spanish literature with searches of Pubmed, Scopus, Ovid Embase and Ovid Medline. After narrowing to 33 relevant reports, we describe 90 reported cases worldwide from 2004 to 2017, in addition to a new case from our institution as a means of comparison. We found that BHD was common in elderly men (mean age 72 ± 12; male:female, 1.9:1) and typically occurred within 7 days of administration of anticoagulation (median 7 days ± 6.4) usually with enoxaparin use (66% of cases). Lesions occurred primarily on the extremities only (67.9% of cases). Coagulation testing was most often normal before administration, and the majority of patients had coagulation testing in therapeutic range during treatment. Most practitioners stopped anticoagulation if continued therapeutic intervention was no longer required (57% of cases), or changed therapy to another anticoagulation if continued treatment was required (14.3% of cases). Therapy was continued outright in 23% of patients. The lesions usually resolved within 2 weeks (mean days, 13.0 ± 7.4). There was no difference in time to resolution between patients who continued the culprit anticoagulant or changed to a different anticoagulant, and those who discontinued anticoagulation altogether (13.9 days vs. 12.1, p = 0.49). Four deaths have been reported in this clinical context, two specified as intracranial hemorrhage. These deaths were unrelated to the occurrence of BHD. Continuation of low-molecular weight heparins appeared to be safe in patients with BHD.
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Affiliation(s)
- Armand Russo
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
| | - Susanna Curtis
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
| | - Raisa Balbuena-Merle
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT 06511 USA
| | - Roxanne Wadia
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
- VA Connecticut Healthcare System, Cancer Center, 950 Campbell Avenue, Mailcode 111D, West Haven, CT 06516 USA
| | - Ellice Wong
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
- VA Connecticut Healthcare System, Cancer Center, 950 Campbell Avenue, Mailcode 111D, West Haven, CT 06516 USA
| | - Herta H. Chao
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
- VA Connecticut Healthcare System, Cancer Center, 950 Campbell Avenue, Mailcode 111D, West Haven, CT 06516 USA
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