Warfarin-induced skin necrosis: a rare condition

Abstract

Warfarin induced skin necrosis is a rare debilitating and, in some cases, life-threatening complication. A 47-year-old male on life-long anticoagulation omits his medication and develops extensive skin necrosis of the left leg complicated by acute renal failure three days after restarting warfarin. Investigations reveal possible Protein S deficiency which is known to be a predisposing condition. Various mechanisms have been proposed as the underlying cause. He was managed on heparin, wound debridement and skin grafting. Warfarin was restarted concurrently with heparin. Knowledge of this complication will enable timely diagnosis and treatment.

Warfarin‐induced skin necrosis after the use of an anticoagulation reversal agent

“…These patients may be treated with warfarin in the future, but small dosages (2–5 mg daily) are recommended, with initial treatment under heparin coverage 1 . Reintroduction of therapy with warfarin has produced variable results and remains controversial; some report recurrence or worsening of the skin necrosis, whereas others report no recurrent thrombosis 10 …”

“…1 Reintroduction of therapy with warfarin has produced variable results and remains controversial; some report recurrence or worsening of the skin necrosis, whereas others report no recurrent thrombosis. 10 Although WISN is a rare condition, it remains an important differential diagnosis to consider, especially in patients who have recently commenced or recommenced warfarin. The use of Prothrombinex-VF should also be highlighted as a potential risk factor as it can also induce a hypercoagulable state.…”

Inflammatory skin diseases and wounds

“…The pathogenesis of coumadin necrosis is unclear and affects 0Á1% of patients newly initiated on coumadins. 35 It appears that the treatment decreases protein C and protein S activity, promoting a hypercoagulable state, but there is also a potential toxic effect of coumadin on papillary dermal microvessels. Factor V Leiden mutation is a coagulation defect that can lead to postthrombotic venous leg ulcers and cutaneous necrosis, especially in homozygous affected individuals, due to an up to 100-fold increased tendency to thrombosis.…”

“…Protein C and protein S are vitamin K‐dependent plasma proteins whose deficiencies are inherited or acquired vasculopathies that affect coagulation and fibrinolysis. The pathogenesis of coumadin necrosis is unclear and affects 0·1% of patients newly initiated on coumadins 35 . It appears that the treatment decreases protein C and protein S activity, promoting a hypercoagulable state, but there is also a potential toxic effect of coumadin on papillary dermal microvessels.…”

Warfarin-Induced Skin Necrosis in a 14-Year-Old Female: A Case Report

“…Warfarin is an oral anticoagulant that is commonly prescribed to patients with venous thromboembolism, pulmonary embolism, and mechanical heart valve replacements. Several common adverse effects, such as bleeding and skin necrosis, have been linked to the use of warfarin [ 1 ]. There is a rare but devastating side effect of oral anticoagulant therapy termed warfarin-induced skin necrosis (WISN) [ 2 ].…”