Enoxaparin-Induced Bullous Hemorrhagic Dermatosis and Enoxaparin Rechallenge: A Case Report

Purpose: A case of enoxaparin-induced bullous hemorrhagic dermatosis is reported. Summary: A 69-year-old male with past medical history including chronic atrial fibrillation and a re-do aortic valve replacement, anticoagulated on warfarin, received an enoxaparin bridge for a molar extraction. On day 7 after restarting enoxaparin post-procedure at a therapeutic dose of 90 mg every 12 hours, the patient noticed multiple small, dark, raised lesions on his forearm and ankle. The patient denied pain, itchiness, or initiation of new medications other than enoxaparin. The patient had never experienced this side effect in the past, although he had two prior exposures to enoxaparin. A review of the available literature on cutaneous side effects from enoxaparin was performed and it was determined that the patient experienced enoxaparin-induced bullous hemorrhagic dermatosis. There is currently limited guidance on management of this rare side effect and whether enoxaparin rechallenge is safe. As benefit outweighed risk for the patient, the enoxaparin bridge was continued for an additional 3 doses, until the patient completed his supply of enoxaparin at home. Approximately within 1 week after enoxaparin was discontinued, the hemorrhagic bullae disappeared. The patient was re-exposed to enoxaparin 6 months later for a colonoscopy and the side effect did not reoccur. Conclusion: It may be safe to continue enoxaparin while experiencing enoxaparin-induced bullous hemorrhagic dermatosis as the condition is typically self-limiting. This case report shows that re-exposure to enoxaparin may be safe as it may not result in reoccurrence of the side effect.