Nose Necrosis in Female Shocked Patient: Conservative Treatment with Heparin

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Case Report
Volume 7 • Issue 4 335
Nose Necrosis in Female Shocked Patient: Conservative Treatment with
Heparin
Marco Stabile MD*, Luca Rosato MD and Valeria Navach MD
Aliation:
Plastic Surgery Unit Piacenza Hospital, Italy
*Corresponding Author
Marco Stabile, Head of Plastic Surgery Unit
Piacenza Hospital, Italy.
E-mail: marcostabile@gmail.com
Citation: Marco Stabile, Luca Rosato, Valeria
Navach. Nose Necrosis in Female Shocked Patient:
Conservative Treatment with Heparin. Archives
of Clinical and Medical Case Reports. 7 (2023):
335-337.
Received: January 06, 2023
Accepted: February 07, 2023
Published: August 03, 2023
Introduction
Acute skin failure is an event in which skin and underlying tissue die
due to hypoperfusion concurrent with a critical illness [1]. Usually skin
hypoperfusion is a late symptom in a shock setting and it is present in
patients with an advanced multiorgan failure (MOF) dysfunction. Acute
skin damage is mainly present in feet and hands as consequence of distal
hypoperfusion due to hypotension or microthrombotic events [2]. Face is
less commonly aected. In some cases of purpura fulminas there is anyway
an important face skin involvement. Purpura fulminans is usually associated
with meningococcal sepsis, varicella, and pneumococcal infections and\or
coagulation disorders [3-4]. We present the clinical case of a young woman
occurring at our hospital with nose skin necrosis as rst sing of shock setting.
Case History
A 38 years old woman presented at the Emergency Department in sleepy
state, generalized malaise and fever unresponsive to paracetamol. The patient
had marbling on the extremities and on the face. The anamnestic investigation
did not reveal anything of clinical signicance. After 24 hours, the clinical
picture turned into septic shock with intravascular disseminated coagulation.
Marbling of the extremities persisted and on the nose it progressed in partial
necrosis. Clinical blood and cerebrospinal uid samples tests were negative;
anyway empiric therapy with vancomycin and meropenem was started.
Renal and hepatic function resulted compromised. Blood support circle
(noradrenaline and dopamine therapy) was administered for the rst 3 days.
Breathing support was necessary for 2 days, and then only occasionally
oxygen support was requested. Subcutaneous therapy with enoxaparine was
administered (4000 UI per day) until discharge. Single dose of Antithrombin
III was given on third day. After 72 hours the patient quickly recovered.
The clinical picture and the multiorgan failure state progressively improved
and patient was transferred from intensive care to infective department. The
specialist haematological consultation and all tests carried didn’t revealed
pathologies of haematological branch.
Three days after recovery the plastic surgeon was called for the evaluation
of facial injuries. The patients showed a full thickness necrosis of the skin of
the tip of nose and faded marbling of the rest of the nose and cheeks (Figure 1).
Conservative treatment was chosen and started with daily topic applications
of "Epsodilave 250 UI / 5ml" (sodic heparin) and greasy gauze dressing. Two
days after, the necrosis showed an improvement and it was limited to the more
distal areas of the nose (Figure 2). The topical treatment continued for 18 days
until the patient was discharged. No surgical or chemical debridement was
carried out. Extremities marbling had a spontaneous regression. One month
later, the patient came to control showing a complete remission and resolution
without signicant scarring (Figure 3).

Marco Stabile MD, et al., Arch Clin Med Case Rep 2023
DOI:10.26502/acmcr.96550625
Citation: Marco Stabile, Luca Rosato, Valeria Navach. Nose Necrosis in Female Shocked Patient: Conservative Treatment with Heparin. Archives
of Clinical and Medical Case Reports. 7 (2023): 335-337.
Volume 7 • Issue 4 336
Discussion
Acute skin necrosis due to severe and prolonged
hypotension can be present in advanced shock settings.
Usually extremities are aected, because of their distinctive
vascular pattern. These signs become evident later respect to
other shock typical symptoms [5]. In our case, skin failure
was an early expression of critical illness status. Later the
patient got worse in a MOF status, with compromised renal
and hepatic function. The unique localization of the nose skin
necrosis addressed clinicians towards a purpura diagnosis.
All examination (blood coagulation pattern, absence of
meningococcal infection in blood and cerebrospinal uid)
contradicted this hypothesis. The hematologist also excluded
any disease of hiss clinical branch. We nally concluded the
damage at nose skin was due solely to hypoperfusion. Nose
has a rich vascularization from facial artery in the lower part
and from angular branch in the upper part. All these branches
anastomose at the lateral sides. Nasal tip lacks anyway of a
strong vascularization and it is more prone to hypoperfusion.
There are not standardized treatments for acute skin
failure, maybe also because in a life threatening setting,
treatment of skin lesions is not considered relevant. Minor
lesions can regress after reset of blood circle, but established
skin necrosis needs specic treatment. The nasal soft tissue
envelope is composed of fat, muscle, overlying supercial
musculoaponeurotic system, and skin. The caudal half of
the nose contains also a higher density of sebaceous glands
[6]. Surgical debridement in case of nose skin necrosis
is commonly discouraged. The deeper sebaceous layers
especially at the tip, have an important regenerative capacity,
so conservative procedures are preferred. Many topical
treatments are described in literature. Use of vasodilators
such as ointment with nitroglycerine and systemic or topical
treatment with pentoxifylline or prostaglandin E1 were used.
Hyperbaric treatment is also described by some authors. The
cost and the management of these treatments are not often
suitable for critical illness patients. In our experience, we had
good results in the topic use of heparin on burns and skin
necrosis, that’s why we routinely use it for cutaneous lesions
that need conservative treatment.
Ng in his review of literature underlines that topic
treatment with gel containing heparin improves or positively
alter the microcirculation in normal skin at both deep
and supercial capillary layers [7]. Also patients with
microangiopathy and have a signicant improvement after
treatment with topical use of heparin. Heparin molecule is
a long glycosamminoglicane. Apart its role in coagulation
process, it has also anti-inammatory property. For this
reason heparin and its derivate are also used in the treatment
of asthma, inammatory bowel disease, cardiopulmonary
bypass, and cataract surgery [8]. Many mechanisms
are involved in the anti-inammatory eect. Levels of
Figure 1: Full thickness necrosis of the skin of the tip of nose and
faded marbling of the rest of the nose and cheeks.
Figure 2: The necrosis showed an improvement and limited to the
more distal areas of the nose.
Figure 3: Complete remission and resolution without signicant
scarring.

Marco Stabile MD, et al., Arch Clin Med Case Rep 2023
DOI:10.26502/acmcr.96550625
Citation: Marco Stabile, Luca Rosato, Valeria Navach. Nose Necrosis in Female Shocked Patient: Conservative Treatment with Heparin. Archives
of Clinical and Medical Case Reports. 7 (2023): 335-337.
Volume 7 • Issue 4 337
citocytokines after heparin administration are decreased (IL
6, IL 8, TNF) and heparin also inhibits adhesion of leukocytes
and neutrophils to endothelial cells.
The topical use of heparin on damaged skin has been long
described in the treatment of burns by Saliba with excellent
results in terms of healing; scarring and pain control [9-10].
At our advice the use of topical heparin is a valid treatment
in case of skin damage due to vascular impairment. We
recommend trying this before surgical debridement.
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