Journal of Cutaneous and Aesthetic Surgery

: 2020  |  Volume : 13  |  Issue : 2  |  Page : 154--159

A basic algorithmic surgical approach for Nicolau syndrome

Ali Yeniocak1, Osman Kelahmetoğlu1, Mustafa Özkan2, Metin Temel3, Ethem Güneren1,  
1 Department of Plastic, Reconstructive and Aesthetic Surgery, Medical Faculty, Bezmialem Vakıf University, Istanbul, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Mustafa Kemal University, Serinyol Hatay, Turkey
3 Private Practice, Serinyol Hatay, Turkey

Correspondence Address:
Osman Kelahmetoğlu
Department of Plastic, Reconstructive and Aesthetic Surgery, Bezmialem Vakif University, Adnan Menderes Bulvarı Vatan Caddesi 34093 Fatih, Istanbul.


Background: Nicolau syndrome (NS) is a rare complication that develops after the administration of intramuscular diclofenac sodium. The etiology and surgical treatments of 11 patients with NS were evaluated and studies in the literature were examined. The aim of this study was to compose a basic algorithm for surgical approaches to treat NS. Materials and Methods: Eleven patients were evaluated for NS between December 2013 and January 2018. Two patients did not accept treatment, and nine patients underwent surgical debridement of necrotic tissues. The tissue defects of five patients were closed with a fasciocutaneous flap and, in four patients, the defects were repaired primarily. Results: No complications, such as wound infection, wound dehiscence, seroma, or flap necrosis, were encountered. Of the seven patients who received concurrent antibiotic therapy, no patient had any problems at their follow-up (2–30 months). The results were satisfactory from an aesthetic and functional point of view. Conclusion: NS was more frequent in women with a high body mass index and high fat in gluteal regions. We considered that any kind of medication could lead to NS. Different methods are discussed for treatment.

How to cite this article:
Yeniocak A, Kelahmetoğlu O, Özkan M, Temel M, Güneren E. A basic algorithmic surgical approach for Nicolau syndrome.J Cutan Aesthet Surg 2020;13:154-159

How to cite this URL:
Yeniocak A, Kelahmetoğlu O, Özkan M, Temel M, Güneren E. A basic algorithmic surgical approach for Nicolau syndrome. J Cutan Aesthet Surg [serial online] 2020 [cited 2022 Jan 18 ];13:154-159
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Full Text


Nicolau syndrome (NS), also known as Embolia cutis medicamentosa or livedoid dermatitis, is a complication that occurs subsequent to intramuscular (IM) injection of various drugs. The condition can often be overlooked.[1] It first presents as pain around the injection site and develops as inflammation in the skin, the underlying adipose tissue, and in the muscle.[2]

The condition has been associated with almost all drug classes, including nonsteroidal anti-inflammatory drugs (NSAIDs),[3] local anesthetic agents,[4] corticosteroids,[5],[6] antibiotics,[7],[8],[9] vitamin B complex, vitamin K,[10] oxytocin,[11] antineoplastics,[12],[13],[14] antihistamines, and vaccines.[15] The most acute form of the complication occurs after NSAID injections.[16],[17] In one case, a cold compress applied for local pain management was reported to have increased acute local effects, rapidly leading to necrosis.[18]

Although the etiopathogenesis of the condition remains unclear, the most prevalent explanation is accidental penetration of the drug into the intravascular area during IM injection, leading to erythema and a livedoid reticular and/or hemorrhagic wound secondary to arterial thrombosis. The reaction can lead to necrosis and ulceration of the skin, subcutaneous adipose tissue, and muscular tissue.[18]

IM injections are widely administered both in and outside of hospitals. Given that they are not performed by health-care professionals and performed under non-sterile conditions, those performed in nonhospital settings can lead to complications, such as NS. Therefore, it is important to be able to identify and manage NS.

In this study, we present the treatment results of nine patients who received basic surgical approaches to treat NS.

 Materials and Methods

We retrospectively evaluated 11 patients who were treated or referred to our department for wounds, and eventually diagnosed with NS between December 2013 and January 2018. Patient data on age, gender, height, and weight, etiology/drug and site of the IM injection, and reconstruction techniques for defect closure were recorded. Body mass index (BMI) was calculated, and concomitant diseases and medications were recorded.


Of the 11 patients (nine female and two males; mean age: 52.5, range: 24–78 years) who were diagnosed with NS, two did not accept treatment. NS had occurred after IM diclofenac sodium injection in eight patients, and after IM ceftriaxone injection in three patients. Seven patients presented with typical postinjection NS lesions in the right gluteal region, and three patients developed lesions in the left gluteal region [Figure 1]. One patient presented with a lesion in bilateral anterior thighs. Initial surgical debridement was performed in all nine of the treated patients. Culture samples were taken from four patients, of which one was reported contaminated. Extended-spectrum β-lactamase-producing Escherichia coli was seen in two wound cultures and Klebsiella pneumoniae was detected in one wound culture. Infected patients were started on antibiotics according to the antibiogram after consulting the infectious disease department. Of the 11 patients, five had diabetes mellitus, six had hypertension, and one had liver cirrhosis. The injections were administered by health-care professionals in eight patients and by their relatives in three patients. All patients reported a history of multiple injections. Negative pressure wound therapy was used for 6–19 days in all seven patients after debridement. Although granulation tissue developed in six patients, one patient required a second debridement procedure. Fasciocutaneous flaps were used in five patients and defects were primarily closed in four patients [Figure 2] and [Figure 3]. Patients were discharged on days 2–8 (mean, 3 days). No complications, such as wound infection, wound dehiscence, seroma, or flap necrosis, were encountered in any of the patients. No postoperative complications were observed in any of the nine patients throughout their mean 12-month follow-up period.{Figure 1}, {Figure 2}, {Figure 3}

All nine female patients were obese (BMI 34–47, mean 40.44kg/m2). The BMIs of the two male patients were 30 and 40. The overweight female patients frequently received IM NSAID injections for pain. Demographic data, concomitant diseases, and treatment methods of the patients are given in [Table 1].{Table 1}


NS was first described by Nicolau in 1925 following IM injections of bismuth salt to treat syphilis.[19] Since then, many drugs have been reported to cause NS. As most of these drugs are routinely used in clinical practice, diagnosis and treatment of NS are important.

The etiopathogenesis of the condition remains unclear, but it is suggested to be the development of a livedo-like dermatitis secondary to arterial thrombosis as a result of the accidental penetration of the drug into the intravascular area during an IM injection.[6],[17] Navrazhina et al.[20] reported performing a biopsy and tissue culture from a purpura-like NS plaque area that developed after a lumbar puncture. Although the tissue culture failed to grow, the biopsy result was reported as “pauci-inflammatory thrombogenic vasculopathy affecting the capillaries and venules throughout the dermis and subcutaneous fat with endothelial necrosis and sloughing into vascular lumens.” Another theory suggests that perineural, intra-arterial, and periarterial injections cause local pain, and vasospasm secondary to the local pain leads to sympathetic nerve stimulation followed by necrosis in cutaneous, subcutaneous, adipose, and/or muscle tissues.[18] Most cases in the literature are reported to have occurred after a diclofenac sodium injection.[1],[18],[21] An IM diclofenac sodium injection was the causative agent in 8 of our 11 patients. The development of NS after injecting NSAIDs suggests that the condition may be associated with the pharmacological characteristics of this drug group. NSAIDs inhibit prostaglandin synthesis by inhibiting cyclooxygenase. Ischemic necrosis develops once prostaglandin is suppressed by the drug and vasospasm is induced.[21] Some studies also indicate that NS has no allergic or immunological origins. There were no findings of NS after the treated patients received IM injections containing the same causative agent.[18],[22]

Although NS is mostly reported to be caused by IM-administered drugs, as compiled in the table given in Nischal et al.,[23] it is also caused by intravenous, intra-articular, and glucocorticoid injections, as well as by subcutaneously and subacromially injected drugs.

Although NS is a rare condition, IM injections increase the possibility of occurrence, particularly in obese patients.[22] A mean BMI of 41.28 (high-health risk level) in our female patients and 35 (overweight) in our male patients suggest that weight can be a significant risk factor in the occurrence of NS. Dadaci et al.[24] reported measuring the thickness of the adipose tissue on pelvic tomography images of gluteal injection sites, and concluded that green needles (3.8cm in depth) do not penetrate deep enough to pass the adipose tissue and reach the gluteal region.[24] Adipose tissue thickness was 5.4cm on magnetic resonance imaging. A needle depth of 3.8cm indicates that drugs that have toxic effects, disrupt circulation, and increase the risk of fatty necrosis are injected into the adipose tissue instead of the muscle. Furthermore, as a result of cumulative effects, greater inflammation and tissue necrosis were observed in patients receiving repeated injections. The depth of the subcutaneous tissue also varies depending on gender and weight of the patient. IM injections performed with a standard green needle reach the gluteal region in only 5% of women and 15% of men, and the remainder is injected into subcutaneous tissue.[17] Obesity in all of our female patients could have been a risk for NS. Another risk factor is frequent injections, which was present in all nine of our patients. Vascular problems, particularly in obese patients, have led to the increased administration of IM injections, suggesting that the increased rate of injections, both in hospital and nonhospital settings, could be a risk factor for NS.

IM injections should be duly administered by health-care professionals. Complications can be minimized with Z-track method, which is one of the injection methods.[25]

Treatments for NS remain controversial. Surgical debridement, local flaps, and partial-thickness skin grafts can be used to treat lesions with established necrosis. Analgesics, dressings, and antibiotics are useful as conservative treatment methods for pain management in many cases.[26] Some authors have reported using pentoxifylline to reduce blood viscosity, hyperbaric oxygen to increase oxygenation, fibroblast activity and angiogenesis in the wound, and heparin to reduce vascular occlusion.[5],[20],[26] There are also reports of using nifedipine, a calcium channel blocker, for its arterial vasospasm-reducing effects and systemic steroids for their inflammation-suppressing characteristics.[5],[7] There is no standardized treatment for NS; the current aim was to prevent the condition from developing into soft tissue necrosis.[5] In many cases, surgical debridement should be considered to support wound healing and to reduce the risk of infection.[20] In their report of a 9-year-old patient who developed NS on the fingers after a penicillin injection into the deltoid muscle, Memarian et al.[7] described treating the patient with intravenous hydrocortisone, subcutaneous enoxaparin, and local trinitroglycerin. In addition, Alkan et al.[27] reported treating a 4-year-old patient with pentoxifylline and heparinization for NS caused by a penicillin injection, but the treatment was initiated immediately after the injection, before necrosis developed. Surgical debridement was primarily performed in all of our patients as all presented with the typical dark-colored lesion seen in NS. Although the best aesthetic outcomes can be achieved with primary closure, except in large wounds, partial thickness skin grafts will take time to heal if atrophic scarring and hyperpigmentation occur. Flaps are the best option for larger gluteal defects.[28] Kocman et al.[28] reported treating five NS patients with free-style perforator V-Y flaps designed vertically or horizontally according to the long axis of the wound. This provided reduced donor site morbidity and less tension on the recipient site.[28]

Pain around the site after injection, followed by erythematous, livedoid, and hemorrhagic formations and, ultimately, cutaneous, subcutaneous, adipose tissue, and muscular tissue necrosis were seen in the reported cases. Necrosis in related dermatomes is pathognomonic for NS.[29]

In our study, the wounds were primarily closed after surgical debridement in four patients, and a fasciocutaneous flap was used in five patients. In their case series of 17 patients with NS, Dadaci et al.[24] reported treating the wounds with primary closure in 11 patients and reconstructing with local flaps in six patients (four with Limberg flaps and two with V-Y advancement flaps). There are reports of NS cases reconstructed with partial-thickness skin grafts[20],[23],[26] and full-thickness skin grafts[17] after surgical debridement. These cases healed with residual depressed scars. In their study of three patients, Seok-Kwun et al.[26] reported using a partial-thickness skin graft in one, primary closure in one, and bilateral advancement flap in the other case. We designed an algorithmic approach for surgical repair [Figure 4]. Surgical debridement and antibiotics should be given in cases of necrosis and infection. Vacuum treatment may be necessary to mature and granulate wounds that are not infected but are not ready for reconstruction. Skin grafts should be considered in cases where primary closure and faciokutan flap selection are not possible.{Figure 4}


NS was more frequent in women with a high BMI and high fat in the gluteal region, particularly those with NS. We considered that any kind of medication could lead to this syndrome. Different treatment methods were discussed and we developed a basic, efficient surgical algorithm for NS.

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.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Park HJ, Kim MS, Park NH, Jung SW, Park SI, Park CS. Sonographic findings in Nicolau syndrome following intramuscular diclofenac injection: a case report. J Clin Ultrasound 2011;39:111-3.
2Hamilton B, Fowler P, Galloway H, Popovic N. Nicolau syndrome in an athlete following intra-muscular diclofenac injection. Acta Orthop Belg 2008;74:860-4.
3Kılıç İ, Kaya F, Özdemir AT, Demirel T, Çelik İ. Nicolau syndrome due to diclofenac sodium (Voltaren®) injection: a case report. J Med Case Rep 2014;8:404.
4García-Vilanova-Comas A, Fuster-Diana C, Cubells-Parrilla M, Pérez-Ferriols MD, Pérez-Valles A, Roig-Vila JV. Nicolau syndrome after lidocaine injection and cold application: a rare complication of breast core needle biopsy. Int J Dermatol 2011;50:78-80.
5McKinney C, Sharma N, Jerath RS. Livedoid dermatitis (Nicolau syndrome) following intra-articular glucocorticoid injection. J Clin Rheumatol 2014;20:339-40.
6Cherasse A, Kahn MF, Mistrih R, Maillard H, Strauss J, Tavernier C. Nicolau’s syndrome after local glucocorticoid injection. Joint Bone Spine 2003;70:390-2.
7Memarian S, Gharib B, Gharagozlou M, Alimadadi H, Ahmadinejad Z, Ziaee V. Nicolau syndrome due to penicillin injection: a report of 3 cases without long-term complication. Case Rep Infect Dis 2016;2016:9082158.
8Kim DH, Ahn HH, Kye YC, Choi JE. Nicolau syndrome involving whole ipsilateral limb induced by intramuscular administration of gentamycin. Indian J Dermatol Venereol Leprol 2014;80:96.
9Lee DP, Bae GY, Lee MW, Choi JH, Moon KC, Koh JK. Nicolau syndrome caused by piroxicam. Int J Dermatol 2005;44:1069-70.
10Koklu E, Sarici SU, Altun D, Erdeve O. Nicolau syndrome induced by intramuscular vitamin K in a premature newborn. Eur J Pediatr 2009;168:1541-2.
11Mancano MA. Delayed anaphylaxis with methimazole: Nicolau syndrome after oxytocin intramuscular administration anastrazole-induced autoimmune hepatitis amoxicillin- and cephalexin-induced eosinophilic colitis docetaxel-induced supravenous erythematous eruption. Hosp Pharm 2016;51:520-3.
12Lobato-Berezo A, Martínez-Pérez M, Imbernón-Moya A, Gallego-Valdés MÁ. [Nicolau syndrome after glatiramer acetate injection]. Med Clin (Barc) 2015;145:e41.
13Almudimeegh A, Le Pelletier F, Dupin N. Nicolau syndrome secondary to subcutaneous bortezomib injection. J Eur Acad Dermatol Venereol 2016;30:348-50.
14Guarneri C, Polimeni G. Nicolau syndrome following etanercept administration. Am J Clin Dermatol 2010;11:51-2.
15Nagore E, Torrelo A, González-Mediero I, Zambrano A. Livedoid skin necrosis (Nicolau syndrome) due to triple vaccine (DTP) injection. Br J Dermatol 1997;137:1030-1.
16Luton K, Garcia C, Poletti E, Koester G. Nicolau syndrome: three cases and review. Int J Dermatol 2006;45:1326-8.
17Kim KK. Nicolau syndrome in patient following diclofenac administration: a case report. Ann Dermatol 2011;23:501-3.
18Engin Ş. Nicolau syndrome as an avoidable complication. J Fam Community Med 2012;19:52-3.
19Varga L, Asztalos L. Nicolau syndrome after ketazon injection. Orv Hetil 1990;131:1143-6.
20Navrazhina K, Cressey BD, Wildman HF. Nicolau syndrome after lumbar puncture: a case report in a 22-month-old girl. JAAD Case Rep 2017;3:33-5.
21Lie C, Leung F, Chow SP. Nicolau syndrome following intramuscular diclofenac administration: a case report. J Orthop Surg (Hong Kong) 2006;14:104-7.
22Noaparast M, Mirsharifi R, Elyasinia F, Parsaei R, Kondori H, Farifteh S. Nicolau syndrome after intramuscular benzathine penicillin injection. Iran J Med Sci 2014;39:577-9.
23Nischal KC, Basavaraj HB, Swaroop MR, Agrawal DP, Sathyanarayana BD, Umashankar NP. Nicolau syndrome: an iatrogenic cutaneous necrosis. J Cutan Aesthet Surg 2009;2:92-5.
24Dadaci M, Altuntas Z, Ince B, Bilgen F, Tufekci O, Poyraz N. Nicolau syndrome after intramuscular injection of non-steroidal anti-inflammatory drugs (NSAID). Bosn J Basic Med Sci 2015;15:57-60.
25McConnell EA. Administering a Z-track i.m. injection. Nursing 1999;29:26.
26Seok-Kwun K, Tae-Heon K, Keun-Cheol L. Nicolau Syndrome after Intramuscular Injection: 3 Cases. Arch Plast Surg 2012;39: 249-52.
27Alkan BT, Demirel G, Ormeci T, Al S, Çakar E, Tastekin A, et al. Anticoagulant and vasodilator therapy for Nicolau syndrome following intramuscular benzathine penicillin injection in a 4 year old boy. Arch Argent Pediatr 2016;114:e184-6.
28Kocman EA, Yaşar FN, Kose AA, Cil Y, Karabagli Y, Çetin C. Freestyle perforator-based fasciocutaneous flap reconstruction in Nicolau syndrome-related tissue necrosis. Indian J Surg 2015;77:1187-90.
29Nisbet AC. Intramuscular gluteal injections in the increasingly obese population: retrospective study. BMJ 2006;332:637-8.