Intraepidermal bullous haemorrhage during anticoagulation with low-molecular-weight heparin: two cases

Conflicts of interest: none declared. Sir, Recently, an unusual adverse reaction to low‐molecular‐weight heparin characterized by acute onset of haemorrhagic lesions was described.1 We report two further patients with a similar condition. Patient 1 is a 72‐year‐old woman who developed multiple, partly grouped, variably large, sharply demarcated haemorrhagic blisters and small bullae on the abdomen and upper extremities (Fig. 1a). The patient had pulmonary artery hypertension and was under treatment with oral anticoagulants, which were stopped and substituted with low‐molecular‐weight heparin because of a planned heart catheter investigation. The lesions appeared 2 days after beginning the heparin treatment (sodium enoxaparin). There was no history of trauma to the affected sites. Clinically, lesions resembled angiokeratomas or superficial haemorrhages, and were not located at the site of injection of heparin. The perilesional skin showed only focally minimal signs of inflammation. A biopsy was taken from one lesion on the abdomen. Routine laboratory examinations were within normal levels, including platelet count. Coagulation parameters were as follows: decreased prothrombin time (56%, normal 70–120); fibrinogen level slightly elevated (569 mg dL−1, normal 210–400); activated partial thromboplastin time (APTT) prolonged (> 160 s, normal 26–36).