Livedoid Dermatitis and Severe Necrosis (Nicolau’s Syndrome) After Intramuscular Hydroxyzine Injection

Abstract

Nicolau's syndrome, also called embolica cutis medicamentosa, is characterized by well- circumscribed livedoid dermatitis with aseptic necrosis after intramuscular injection. We report the case of a 45-year-old woman with severe necrosis of the thigh several days after a routine intramuscular injection of hydroxyzine who was transferred to and treated at our Regional Burn Center. Although there has been one case report and numerous voluntarily reported instances of intramuscular hydroxyzine-induced necrosis to the Food and Drug Administration Spontaneous Reporting System, this phenomenon is rare.

Síndrome de Nicolau de desenvolvimento tardio: relato de caso

“…4,5 It is well described in the dermatological literature as a rare adverse reaction characterized by dermatitis livedoid 3,4,5,7 that occurs after intramuscular injection of insoluble substances. 4,7,8,9 However, the emergence of the syndrome is related to the pharmaceutical form of the drug and the way the remedy is applied and not with its pharmacodynamic properties and, therefore, there is not an specific group responsible for its complication potential. Systematic review showed predisposing factors such as aqueous micro-suspension in contrast with oily vehicle suggesting a prevalent genesis of embolism syndrome.…”

“…Initially, the patient presents severe and acute pain after the injection. 3,5,7,8,10 After that, developing a erythematous rash on the injection site, with formation of a halo of pallor around the area, 10 with a livedoid pattern 3,5,12 that slowly evolves into skin, subcutaneous and ,sometimes muscular necrosis. 10,13 In some patients it can progress to bullae in the site of the injection.…”

Late development Nicolau Syndrome: A case report

“…It is well described in dermatologic literature as a rare side effect characterized by livedoid dermatitis [3][4][5]7] which occurs after the intra-muscular injection of insoluble substances [4,[7][8][9] Nevertheless, the emergence of the Syndrome is associated with the route of administration and the new pharmaceutical formula of the drug, rather than with its pharmacodynamic properties, and consequently, there is not a specific group responsible for the complication potential. A systematic review showed that predisposing factors, such as watery micro-suspension in the vehicle, in opposition to oily, suggesting a prevalent genesis of the Syndrome's embolism [10] .…”

“…Initially, the patient manifests a serious, acute and severe pain after the injection [3,5,7,8,10]. Afterwards, comes the development of an exanthema erythematosus around the injected area [10], with the formation of a halo of pallor surrounding the region, and of a livedoid pattern [3,5,12], which slowly evolves into skin necrosis, subcutaneous, e sometimes, muscular [10,13].…”

Freestyle Perforator-Based Fasciocutaneous Flap Reconstruction in Nicolau Syndrome-Related Tissue Necrosis

“…The actual physiopathology of the NS is yet unknown; it has been proposed that the direct arterial damage and vasoconstrictive effects of various drugs may induce inflammation and subsequently cause skin necrosis [2,3]. Agents, such as nonsteroidal anti-inflammatory drugs, steroids, vitamines, benzathine penicillin, hydroxyzine, vaccines i.e., are reported to be potential triggering factors of this clinical entity [2,[4][5][6][7][8][9][10][11][12][13]. There is no consensus on the treatment protocol of the disease.…”