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Low molecular weight heparin-induced skin necrosis—a systematic review

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Abstract

Background

Low molecular weight heparins (LMWHs) are currently used as a standard for anti-thrombotic therapy. Skin necrosis caused by LMWH is a rare and probably under-reported complication. The aim of our systematic review is to analyse the present literature for cases of LMWH-induced skin necrosis, emphasising the pathogenesis, clinical pattern, and management of this rare side effect.

Methods

We performed a Medline literature search (PubMed database) and manual cross-referencing to identify all articles related to LMWH-induced skin necrosis. Data were analysed for type of LMWH used, time until skin necrosis occurred, localisation, size, laboratory findings, switch anticoagulant, complications, and outcome. Additionally, the case of a patient from our hospital is presented.

Results

We included a total of 20 articles (21 cases) reporting on LMWH-induced skin necrosis. Skin necrosis occurred locally and distant from the injection site. Heparin-induced antibodies were frequently observed (positive 9/11 articles, negative 2/11). However, severe thrombocytopenia (platelet count <100,000 cells/ml) occurred in only four cases, while platelet count remained normal in 50% of the cases. After patients had been switched to other anti-thrombotic drugs, the clinical course was usually benign; however, reconstructive surgery was necessary in two cases.

Conclusion

LMWH-induced skin necrosis may occur as part of the heparin-induced thrombocytopenia (HIT) syndrome, but other pathomechanisms, including allergic reactions and local trauma, may also be involved. When HIT is excluded, unfractionated heparin is a safe switch anticoagulant. Otherwise, non-heparin preparations such as hirudin or fondaparinux should be preferred.

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Acknowledgements

The authors thank PD Dr. T. Bombeli, Division of Haematology, Department of Internal Medicine, University Hospital of Zurich, for assistance and correction of the manuscript.

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Authors and Affiliations

  1. Division of Trauma Surgery, University Hospital of Zürich, Raemistrasse 100, 8091, Zürich, Switzerland

    A. E. Handschin, O. Trentz & G. A. Wanner

  2. Section of Accident and Reconstructive Surgery, Hospital for Surgery, University of Heidelberg, Heidelberg, Germany

    H. J. Kock

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  1. A. E. Handschin
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  2. O. Trentz
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  3. H. J. Kock
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Correspondence to A. E. Handschin.

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Handschin, A.E., Trentz, O., Kock, H.J. et al. Low molecular weight heparin-induced skin necrosis—a systematic review. Langenbecks Arch Surg 390, 249–254 (2005). https://doi.org/10.1007/s00423-004-0522-7

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  • DOI: https://doi.org/10.1007/s00423-004-0522-7

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