Intramuscular diclofenac is a cause of Nicolau syndrome in obese women: An observational study of consecutive ten patients.

Nicolau syndrome is a skin and underlying tissue necrosis resulting from vascular occlusion after various injections of certain drugs. Intramuscular injections are the most common cause but it may occur after other types of parenteral interventions. There are many medications reported as causative factors inducing Nicolau syndrome including penicillin, nonsteroidal anti-inflammatory drugs, corticosteroids, local anesthetics, and several others. We present an observational study of diclofenac induced Nicolau syndrome.

Nicolau syndrome after intramuscular injection of non-steroidal anti-inflammatory drugs (NSAID).

Nicolau syndrome is a rare complication of intramuscular injection that leads to local ischemic necrosis of the skin and adipose tissue. In this paper, we discuss etiologies, risk factors, and treatment options for gluteal Nicolau syndrome referring to patients treated in our hospital. Our study includes 17 women who visited our clinic with symptoms of gluteal necrosis secondary to intramuscular injection. The following variables were taken into account: injection site, drug administered, frequency of injections, the person who administered the injections, needle size, and needle tip color. Magnetic resonance images obtained in the aftermath of intramuscular injection application were carefully analyzed for presence of necrosis, cyst formation and the thickness of the gluteal fat tissue layer. Drugs that had been received in intramuscular injection were exclusively non-steroidal anti-inflammatory drugs. Mean patient BMI was 41.8 (all patients were considered as obese), and mean gluteal fat thickness was 54 mm. Standard length of needles (3.8 cm) had been used in procedures. The wounds were treated with primary closure in 11 patients and with local flap therapy in 6 patients. The observed necrosis was a consequence of misplaced gluteal injection, where drugs were injected into the adipose tissue instead of the muscle due to the extreme thickness of the fat layer, on one hand, and the inappropriate length of standard needles, on the other hand. Intramuscular injection should be avoided in obese patients whenever possible: if it is necessary, proper injection technique should be used.