Rivaroxaban-induced cutaneous leukocytoclastic vasculitis with necrotic ulcerations: A case report

Since their introduction in the early 2000s, direct oral anticoagulants (DOACs), including rivaroxaban, a factor Xa inhibitor, have been widely used for managing atrial fibrillation and venous thromboembolism. Hypersensitivity reactions associated with rivaroxaban are rarely reported, as the drug’s mechanism of action draws significant attention to hemorrhagic adverse effects. Consequently, non-hemorrhagic adverse effects, such as cutaneous reactions, often remain underrecognized. Here, we report the case of a 70-year-old woman with a history of atrial fibrillation and transient ischemic attack (TIA), treated with rivaroxaban, who developed a diffuse petechial rash and a palpable purpura, mainly on her lower extremities, blisters, and ulcerations with necrotic surface after 7 days of therapy diagnosed as leukocytoclastic vasculitis (LCV) via skin biopsy with negative serum anti-neutrophil cytoplasmic antibody (ANCA). Rivaroxaban was identified as the causative agent and discontinued, leading to symptom resolution. This case highlights the importance of recognizing rare cutaneous adverse effects of rivaroxaban to ensure timely diagnosis and management.