Anticoagulants in dermatology.

Anticoagulants are the cornerstone of treatment of venous thromboembolism associated with various medical conditions and surgical procedures. They act on different steps of the coagulation pathway and are broadly categorized into heparins, vitamin K antagonists, and inhibitors of thrombin and factor Xa. The classification is evolving as newer and better oral and parenteral anticoagulants are being added. Anticoagulants in dermatology are important not only for their therapeutic application in cutaneous thrombotic dermatoses such as livedoid vasculitis, purpura fulminans, superficial and deep venous thrombosis and others but also for their use in non-thrombotic dermatoses such as lichen planus, recurrent oral aphthosis, chronic urticaria and several others. Further, the use of anticoagulants for any indication is associated with various adverse effects with dermatologic manifestations including specific reactions such as warfarin-induced skin necrosis, heparin-induced thrombocytopenia and anticoagulant-associated cholesterol embolization syndrome.

Enoxaparin-induced hemorrhagic bullous dermatosis in a leprosy patient.

Enoxaparin is a low-molecular-weight heparin that has been used widely to prevent and treat thromboembolic disorders for at least 30 years. The most common adverse skin reactions to enoxaparin are ecchymosis and skin necrosis due to vasculitis, urticaria, angioedema and erythema. Side effects from heparin administration are rare and usually located at the injection site. However, recent reports have suggested that they can also occur at a distance from the site of injection. Moreover, the etiopathogenesis has not been fully explained. In this article, we present a case of hemorrhagic bullous dermatosis associated with enoxaparin for the treatment of ischemic heart disease that developed in a patient with a past history of lepromatous leprosy.

Medical issues and emergencies in the dermatology office

We review the medical issues and emergencies potentially encountered in the practice of general or surgical dermatology. Traditional guidelines have largely consisted of dated extrapolations from the nondermatologic literature concerning procedures that are primarily irrelevant to dermatology. This article outlines a rational approach to organizing an office emergency plan for anaphylaxis, stroke, status epilepticus, myocardial infarction, and hypertensive crisis. We discuss the literature that has influenced current office behavior regarding endocarditis prophylaxis, the use of electrosurgery with pacemakers, arrhythmogenic drug interactions, vasovagal syncope, lidocaine "allergy," and bleeding complications from oral anticoagulants. Recommendations for managing these issues in a dermatologic context are provided.