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Brief Report
June 2017

Association of Central Nervous System Depression With Topical Brimonidine When Used for Hemostasis: A Serious Adverse Event

Author Affiliations
  • 1Department of Dermatology, SUNY Downstate Medical Center, Brooklyn, New York
  • 2Mohs Micrographic Surgery and Dermatologic Oncology Fellowship, Skin Institute of South Florida, Coral Springs
  • 3Cosmetic Dermatologic Surgery Fellowship, Hollywood Dermatology and Cosmetic Surgery, Hollywood, Florida
  • 4Department of Dermatology, University of Maryland, Baltimore
  • 5Department of Dermatology, Lahey Hospital & Medical Center, Burlington, Massachusetts
  • 6Dermatology and Cutaneous Surgery, Florida International University, Miami
  • 7Mohs and Procedural Dermatology Fellowship, Skin Institute of South Florida, Coral Springs
  • 8Dermatology and Dermatological Surgery, Miller School of Medicine, University of Miami, Miami, Florida
  • 9Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida
JAMA Dermatol. 2017;153(6):575-577. doi:10.1001/jamadermatol.2017.0247
Key Points

Question  Does the use of topical brimonidine, 0.33%, gel as a hemostatic agent pose a risk for central nervous system (CNS) depression?

Findings  We describe 2 patients who presented to dermatology practice for dermatologic procedures complicated by persistent bleeding. Both patients experienced altered mental status and respiratory depression after the application of brimonidine, 0.33%, gel.

Meaning  Topical brimonidine, 0.33%, gel may cause CNS depression when used as a hemostatic agent. Safe criteria for the use of brimonidine as hemostatic agents are unknown. We therefore discourage the use of topical brimonidine for hemostasis until its safety is further studied.


Importance  Minor bleeding is the most common complication of dermatologic surgery. Topical brimonidine, 0.33%, gel has been reported for the use of hemostasis in dermatologic surgery. The safety profile and risk of systemic toxic effects when brimonidine is used topically for hemostasis is unknown.

Objective  To determine the risk of systemic toxic effects of topical brimonidine, 0.33%, gel when used for hemostasis.

Design, Setting, and Participants  In this case series from a private practice (Hollywood Dermatology), 2 patients presented for dermatologic procedures, complicated by persistent bleeding.

Interventions  Patients were treated with 10 g of brimonidine, 0.33%, gel applied under occlusion for hemostasis.

Main Outcomes and Measures  Mental status, cardiopulmonary function.

Results  Both patients experienced deterioration of mental status, respiratory depression, and somnolence. Results from cardiac testing, laboratory workup, and imaging were negative for cardiac or neurologic etiology. Both patients improved in less than 24 hours.

Conclusions and Relevance  Topical brimonidine, 0.33%, gel can result in systemic central nervous system toxic effects when used as a hemostatic agent. At present, it is not possible to define a quantity with which brimonidine can be used safely, nor can a safe wound size be defined. We, therefore, urge against the use of topical brimonidine as a hemostatic agent until its safety is further investigated.

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