SYSTEMIC THERAPY WITH FIBRINOLYTIC AGENTS AND HEPARIN FOR RECALCITRANT NONHEALING CUTANEOUS ULCER IN THE ANTIPHOSPHOLIPID SYNDROME

Skin ulceration is a cutaneous manifestation of the antiphospholipid s yndrome (APS) and is associated with thrombosis of small dermal vessel s. Numerous therapeutic agents have been used but are often ineffectiv e. We describe the efficacy of heparin and fibrinolytic agents [urokin ase and tissue plas minogen activator (tPA)] in the treatment of longs tanding nonhealing cutaneous ulcers. In one patient, heparin plus low dose tPA resulted in healing. In another patient, treatment first with urokinase and heparin, and subsequently with tPA alone, resulted in h ealing. When the ulcer recurred secondary to severe peripheral edema, tPA plus heparin led to complete resolution of the ulcer. This suggest s that fibrinolytic therapy and/or heparin may be useful in other recu rrent thrombotic manifestations of the APS as well. However, it must b e emphatically stressed that since life threatening adverse reactions can occur secondary to hemorrhage, this treatment should be undertaken only after extensive evaluation and close monitoring of the coagulati on status.