Bullous hemorrhagic dermatosis due to enoxaparin use in a bullous pemphigoid patient

Abstract

Adverse reactions of subcutaneous low molecular weight heparin or unfractionated heparin could be complications by bleeding, heparin-induced thrombocytopenia, drug-induced liver injury, osteoporosis, and cutaneous reactions. Heparin-induced skin lesions vary from allergic reactions like erythema, urticaria, eczema to intradermal microvascular thrombosis associated with heparin-induced thrombocytopenia. There is a rare cutaneous complication, called bullous hemorrhagic dermatosis. We experienced this rare case of the cutaneous complication caused by enoxaparin. Several tense bullous hemorrhagic lesions occurred after 3 days of enoxaparin in a known bullous pemphigoid patient who had aortic valve replacement surgery with a mechanical prosthesis. The bullous hemorrhagic lesions were regressed after the discontinuation of enoxaparin but recurred after re-administration. The lesions were controlled by the administration of systemic corticosteroid and alternative anticoagulant. To date, less than 20 cases have been reported worldwide. This is the first case of bullous hemorrhagic dermatosis induced by enoxaparin, a low-molecular-weight heparin in Korea. This is also the first case of bullous hemorrhagic dermatosis in a known bullous pemphigoid patient.

Keywords: Bullous dermatoses; Enoxaparin; Heparin, low-molecular-weight; Hypersensitivity.

Fig. 1. Bullous hemorrhagic lesions. (A) Tense, hemorrhagic bulla on the right forearm. (B) Ruptured hemorrhagic bulla on the right forearm. (C) Regressed skin lesion at 4 weeks after the development.

Fig. 2. Representative figures of histopathological examination. (A) Intradermal vesicle formation with filled red blood cells (×4). (B) Mildly perivascular lymphocytic and a few eosinophilic infiltration in periphery of vesicle. No evidences of vasculitis or intravascular thrombus (×20). (C) C3 deposition of dermo-epidemal junction in immunofluorescence (×10).