Heparin-induced skin lesions

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Presentation transcript:

Heparin-induced skin lesions Ralf Ludwig, MD Department of Dermatology University of Lübeck

Heparin-induced skin lesions: Overview What generated the interest...? Causes of heparin-induced skin lesions Incidence of heparin-induced skin lesions Diagnostic management Therapeutic management

Starting point: Learning from own errow Patient admitted for venous leg ulcer Immobilized due to pain History of „heparin allergy“ Anticoagulation with danaparoid Contact Derm 49:158 (2003)

Starting point: Learning from own errow Patient admitted for venous leg ulcer Immobilized due to pain History of „heparin allergy“ Anticoagulation with danaparoid Fondaparinux tolerated for 2 weeks Contact Derm 49:158 (2003)

Causes of heparin-induced skin lesions 1. Delayed type hypersensitivity; n>300 2. Cutaneous HIT manifestation; n>20 3. Rare causes; n<10 - Immediate hypersensitivity - Recall urticaria - Pustulosis - Necrosis - Haemorrhagia Thromb Haemost 96:611 (2006)

Incidence of heparin-induced skin lesions Thromb Haemost 96:611 (2006)

Prospective epidemiological investigation Heparin > 7 days Internal medicine patient Incidence and cause of heparin-induced skin lesions 24 of 320 (7.5%) with heparin-induced skin lesions All caused by DTH reaction Test-reaction 87% 9% 4% CMAJ 181:477 (2009)

Further epidemiological investigations Cohort Reference Incidence (%) Cause Surgery Schindewolf et al (in prep) 2.0 DTH Internal CMAJ 181:477 7.5 Pregnancy Thromb Haemost 81:668 <1.0 DTH ? Pharmacotherapy 19:1013 2.5 NEJM 362:1586 28.9 19.8 Incidence of heparin-induced skin lesions to LMWH

Diagnosis of heparin-induced skin lesions Differentials DTH History Clinical presentation Exclude HIT (laboratory) Biopsy & histology (Allergologic testing) HIT

History: Risk factors for DTH to heparin Female gender (OR 3.0) Obesety, BMI > 25 (OR 4.6) Duration of therapy, > 9 days (OR 5.9) Pregnacy (?) LMWH preparation (?) LMWH Patients (#) Skin lesions (#) Skin lesions (%) Nadroparin 117 20 17.1 Enoxaparin 204 8 3.9 Fondaparinux 233 1 0.4

Histology: CD3 dominated dermal infiltration H&E CD3

Only s.c. provocation sensitive and specific Allergy testig - Only s.c. provocation sensitive and specific Contact Derm 50:383 (2004)

Summary of diagnostic allgorythm Lancet 380:1867 (2012)

Management of heparin-induced skin lesions Lancet 380:1867 (2012)

Management of heparin-induced skin lesions Lancet 380:1867 (2012)

Management of heparin-induced skin lesions Lancet 380:1867 (2012)

Why fondaparinux..? Fondaparinux > 7 days Internal medicine or surgical patient Incidence and cause of fondaparinux-induced skin lesions 1 of 231(0.4%) with fondaparinux-induced skin lesions Caused by DTH reaction Mayo Clin Proc 85:913 (2010)

Patients with RF for allergy Call for an individulized heparin therapy J Clin Oncol 223:2130 (2005) In oncology patients Patients with RF for allergy Fondaparinux < Enoxaparin / Dalteparin <<< Nadroparin

Thanks to Dept. of Dermatology, JW Goethe University, Frankfurt/Main Manfred Wolter Wolf-Henning Boehncke Roland Kaufmann Division of Angiology, JW Goethe University, Frankfurt/Main Marc Schindewolf Edelgard Lindhoff-Last Red Cross Blood Donor Service, Dessau Hartmut Kroll