Livedoid dermatitis

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Livedoid dermatitis
Other names: Embolia cutis medicamentosa,Nicolau syndrome
Feet affected by livedoid dermatitis

Livedoid dermatitis is a skin reaction that occurs immediately after a drug injection. The reaction eventually leads to variable degrees of necrosis to the skin and underlying tissue. The wound eventually heals, but can lead to atrophic, disfiguring scarring.

The reaction is associated with a range of both injection sites and drugs. It was first reported by Freudenthal in 1924 following an injection of bismuth salts for syphilis. Although initial reports were following intramuscular injections, the reaction has since also been reported following subcutaneous,[1][2] intravenous,[3] and intraarticular injections.[4] Livedoid dermatitis has been reported to occur with many different drug injections, including: penicillins, local anesthetics (e.g. lidocaine), vaccines (e.g. Dtap), corticosteroids, NSAIDs, and more.[5]

Signs and symptoms

Necrosis right buttock.

It presents as an immediate, extreme pain around the injection site, with overlying skin rapidly becoming erythematous, violaceous, or blanched ("ischemic pallor")[6]: 124  and sometimes with reticular pattern.


The cause of this condition is poorly understood. Microscopic examination of affected tissue shows ischemic necrosis,[7] and so various hypotheses exist to explain this ischemia, including vasospasm from needle prick, the injected drug, or cold compresses applied to the wound.


The diagnosis is mainly clinical. Skin biopsies of the site show necrosis caused by ischemia.[7] Radiographic imaging may help to delineate the extent of the wound.


Depending on the extent and state of infection of the wound, the condition may require antibiotics, wound debridement in early stages, and corrective plastic surgery in late stages.[5]

See also


  1. Sonntag, M; Bruch-Gerharz D; Neumann NJ; Hodzic-Avdagic N (2005). "Embolia cutis medicamentosa after subcutaneous injection of pegylated interferon-α". Hautarzt. 56 (968–969).
  2. Harde V; Schwarz T (2007). "Embolia cutis medicamentosa following subcutaneous injection of glatiramer acetate". J Dtsch Dermatol Ges. 5 (12): 1122–1123. doi:10.1111/j.1610-0387.2007.06391.x. PMID 18042092.
  3. Geukens J; Rabe E; Bieber T (1999). "Embolia cutis medicamentosa of the foot after sclerotherapy". Eur J Dermatol. 9: 132–133.
  4. Cherasse A; Kahn MF; Mistrih R; Maillard H; Strauss J; Tavernier C (2003). "Nicolau's syndrome after local glucocorticoid injection". Joint Bone Spine. 70 (5): 390–392. doi:10.1016/s1297-319x(03)00137-4.
  5. 5.0 5.1 Nischal KC; Basavaraj HB; Swaroop MR; Agrawal DP; Sathyanarayana BD; Umashankar NP (Jul–Dec 2009). "Nicolau Syndrome: An Iatrogenic Cutaneous Necrosis". J Cutan Aesthet Surg. 2 (2): 92–95. doi:10.4103/0974-2077.58523. PMC 2918347. PMID 20808597.
  6. James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.
  7. 7.0 7.1 Yebenes M; Gilaberte M; Toll A; Barranco C; Pujol RM (2005). "Localized retiform purpura after accidental intra-arterial injection of polidocanol". Acta Dermatol Venereol. 85 (4): 372–373. doi:10.1080/00015550510027856. PMID 16191871.