Abstract
Contact dermatitis is an inflammatory reaction to an irritant or allergen coming in contact with the skin. In this report, the authors present a case of contact dermatitis in a blood donor, which developed in response to the application of a topical heparin formulation. Topical heparin preparations are regularly used in blood centers for the resolution of hematomas associated with phlebotomy. Blood center personnel must be aware of this possible adverse effect that can add to the discomfort in a donor and use these preparations cautiously.
Keywords: Blood donor, contact dermatitis, hematoma, heparin, phlebotomy
Introduction
Heparin-based topical preparations are regularly used in blood centers for the resolution of superficial hematomas that may happen with phlebotomy. Hematoma at the site of phlebotomy is the extravasated blood forming a localized swelling. The beneficial effect of topical heparin preparations in the treatment of superficial venous thrombosis and hematomas has been previously studied.[1,2] However, adverse reactions to these preparations are rarely reported in blood donors. Authors are reporting a case of contact dermatitis in a blood donor to a topical formulation of heparin used for the resolution of post-phlebotomy hematoma.
Case Report
A 25-year-old male came to the blood center for voluntary blood donation. After registration, counseling and a medical examination were performed as per the National guidelines for blood donor selection and blood donor referral.[3] There was no abnormal medical history. The donor donated 450 ml of whole blood. After removing the phlebotomy needle, a 2 cm × 3 cm swelling was observed at the phlebotomy site. It was immediately managed by applying a cold compress.
Postdonation refreshment was provided and the donor was observed for 15 min. After applying a medicated bandage on the phlebotomy site, a topical heparin preparation (Thrombophob ointment, Cadila Healthcare Ltd. Zydus, India) was applied around the phlebotomy site to accelerate the clearance of hematoma. After five minutes of application, the donor complained of itching and redness around the phlebotomy site. On examination, a well-defined erythematous rash was noted in the area of thrombophob application and a diagnosis of contact dermatitis was made [Figure 1]. There was no systemic involvement. The ointment was immediately removed from the skin surface using dry gauze. The donor was given an oral antihistamine and was counseled regarding the allergy to thrombophob ointment. There was no prior history of known drug allergy in the donor. The thrombophob ointment used was within the date of expiry and was kept under proper storage. The donor was followed up the next day through a telephone conversation. The rash had resolved completely within three hours of onset.
Figure 1.
Erythematous rash limited to the site of thrombophob application
Discussion
Adverse reactions in blood donors are classified as reactions with local and generalized symptoms. According to the report available from the National blood donor Haemovigilance Programme of India (HvPI), the incidence of local adverse donor reactions is 7%–8%, out of which the maximum number accounted for hematomas.[4] Treatment of hematomas in blood donors includes cold compress and application of heparin-based topical preparations such as thrombophob.[5]
Thrombophob is the brand name for a topical preparation containing heparin sodium and benzyl nicotinate, which is commonly used in blood centers for the resolution of hematoma associated with phlebotomy. Heparin acts as an anticoagulant by binding to antithrombin III. Benzyl nicotinate acts as a vasodilator that allows maximum absorption of heparin from the skin surface. The benefits of these topical formulations of heparin in the resolution of hematoma are well discussed.[2]
In blood donors, local allergic reactions can occur due to skin disinfectants like povidone-iodine used for phlebotomy-site preparation or application of medicated adhesive bandage at the phlebotomy site.[4,6,7] However, cases of contact dermatitis due to heparin-based topical preparations are rarely described in blood donors. Three such reactions were reported in blood donors after thrombophob application post-phlebotomy to treat a superficial hematoma. In all three blood donors, the allergy appeared immediately on thrombophob application and they recovered completely within two hours.[8,9]
Authors report a similar case that describes the adverse effect following the application of a heparin-based topical preparation for hematoma resolution in a blood donor. The diagnosis of contact dermatitis due to thrombophob was made because the rash appeared after the topical application and was confined to the area of application. However, it is unclear whether the heparin or the benzyl component of thrombophob was responsible for the erythematous rash, as both can cause an adverse reaction.[10] Allergic reactions due to skin disinfectants and medicated bandages are listed by the HvPI under blood donor adverse reactions.[4] However, cases of allergic reactions due to topical heparin reported in blood donors highlight the need to include it in the list of blood donor adverse reactions by the HvPI. Reporting these cases to the National Donor Hemovigilance will help provide evidence-based recommendations and improve the blood donation process.
This case highlights the need to use topical heparin formulations for postphlebotomy hematomas in blood donors with caution. Proper history taking with a focus on drug hypersensitivity during blood donor screening may help identify donors susceptible to allergic reactions. The topical heparin formulation can be tested before use, especially in donors with a history of hypersensitivity. Donors must be counseled if it ever happens and must be instructed to avoid future use. Proper counseling and postdonation advice can reassure the donor and prevent such adverse reactions in the future. Blood center personnel must be aware of this possible side effect of topical heparin formulations and use it with discretion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
- 1.Belcaro G, Cesarone MR, Dugall M, Feragalli B, Ippolito E, Corsi M, et al. Topical formulation of heparin is effective in reducing the symptoms of superficial venous thrombosis: A monocenter, observer-blind, placebo-controlled randomized study. Panminerva Med. 2011;53:3–11. [PubMed] [Google Scholar]
- 2.Rustempasic N, Solakovic E, Totic D, Djedovic M, Bulja S, Solaković S, et al. Effect of heparin gel on resolution of postoperative subcutaneous haematoma. Med J. 2011;17:271–3. [Google Scholar]
- 3.National Blood Transfusion Council. Guidelines for Blood Donor Selection and Blood Donor Referrals. New Delhi: National Blood Transfusion Council; 2017. [[Last accessed on 2023 Apr 19]]. Available from: https://naco.gov.in/blood-transfusion-services-publications . [Google Scholar]
- 4.Bisht A, Marwaha N, Arora S, Patidar GK, Chhabra R. National blood donor vigilance programme of India: Analysis of donor adverse reactions reported during initial 2 years of implementation (2016 and 2017) Asian J Transfus Sci. 2021;15:1–11. doi: 10.4103/ajts.ajts_195_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Bruising: Information for Blood Donors. Blood Donor Counselling: Implementation Guidelines. Geneva: World Health Organization; 2014. [[Last accessed on 2023 Apr 10]]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310575/ [PubMed] [Google Scholar]
- 6.Dhawan HK, Arora S, Sachdev S, Sharma RR, Marwaha N. Allergic contact dermatitis to antiseptic medicated dressing applied on phlebotomy site. Asian J Transfus Sci. 2010;4:133. doi: 10.4103/0973-6247.67020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Rao S, Bartkus T, Gandhi K, Gibson A, Ventolini G. A post-operative reaction to povidone iodine in a postpartum woman: A case report. Case Rep Womens Health. 2022;34:e00394. doi: 10.1016/j.crwh.2022.e00394. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Basavarajegowda A, Anand D, Krishnappa P. Contact urticaria to thrombophob gel. Glob J Transfus Med. 2022;6:115–6. [Google Scholar]
- 9.Sachan D, Gundrajukuppam DK, Priyadarshini K. Allergic reaction to heparin gel –Adding agony to blood donor. Asian J Transfus Sci. 2022 doi: 10.4103/ajts.ajts_131_21. [doi:10.4103/ajts.ajts_131_21] [Preprint Article] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Thiele JJ, Kaatz M, Schmidt S, Heinemann C, Elsner P. Recurrent erythematous dermatitis artefacta in the face induced by benzyl nicotinate. Exog Dermatol. 2002;1:242–5. [Google Scholar]