ENOXAPARIN-ASSOCIATED DERMAL NECROSIS - A CONSEQUENCE OF CROSS-REACTIVITY WITH HEPARIN-MEDIATED ANTIBODIES

OBJECTIVE: TO describe a patient with enoxaparin-induced dermal necros is and to review previously reported cases of skin manifestations asso ciated with low-molecular-weight heparins. CASE SUMMARY: A 43-year-old white woman with adult respiratory distress syndrome developed locali zed dermal necrosis and thrombocytopenia secondary to subcutaneous adm inistration of unfractionated heparin. Upper extremity thrombi that ha d developed after administration of subcutaneous heparin at an outside hospital were treated with subcutaneous enoxaparin. Although platelet counts remained stable during enoxaparin therapy, dermal necrosis dev eloped at the injection site. Parenteral anticoagulant therapy was dis continued and the necrotic lesions secondary to enoxaparin resolved wi th minimal local care. DISCUSSION: Numerous cases of dermal necrosis s econdary to heparin administration have been reported while this react ion secondary to enoxaparin use has been reported only briefly. It has been postulated that dermal necrosis secondary to heparin is associat ed with heparin-induced thrombocytopenia and is a result of heparin-me diated thrombosis in the microvasculature. Antibodies to heparin have cross-reactivity with enoxaparin; therefore, dermal necrosis secondary to enoxaparin may occur by a similar mechanism, CONCLUSIONS: Although enoxaparin-associated dermal necrosis appears to be a rare occurrence , we advise against the use of enoxaparin or other low-molecular-weigh t heparins in patients with a previous history of heparin-associated t hrombocytopenia or heparin-induced dermal necrosis.