Also called livedoid dermatitis, it is a rare complication of an IM injection. It consists of a local skin necrosis which can extend to deep plans.

It seems due to the thrombotic occlusion of arterioles by compression (injection volume), or direct mechanical trauma by the needle or to the insolubility of the substance injected: oil suspensions, corticosteroids, NSAIDs, local anesthetic, vitamin K. Some vaccines have been implicated.

Signs include pain at the injection site, appearance of erythematous macular lesions followed with a purplish extending network;  blistering appear later and evolves to necrosis and ulceration.

Potential complications: infection, deep necrosis, rhabdomyolysis, neuropathic pain with paresis of the limb.

Treatment: local, sometimes antibiotic therapy.

Anesthetic implications:

protection of the affected limb

References : 

-         Koklu E, Sarici SU,AltunD et al. 
Nicolau syndrome induced by intramuscular vitamine K in a premature newborn. 
Eur J Pediatr 2009; 168: 1541-2.

-         Bellot B, Bonnet C, Retornaz K, Panuel M, Garnier J-M, Dubus J-C, Lurquet A-L 
Complication d’une injection intramusculaire ou syndrome de Nicolau. 
Arch Pédiatr  2014; 21:377-80.

Updated: November 2018