Case & review
Warfarin-induced skin necrosis

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Warfarin-induced skin necrosis is a rare complication of anticoagulant therapy with a high associated morbidity and mortality requiring immediate drug cessation. Cutaneous findings include petechiae that progress to ecchymoses and hemorrhagic bullae. Characteristic dermatopathological findings are diffuse dermal microthrombi with endothelial cell damage and red cell extravasation with progression to full-thickness coagulative necrosis. The lesions of warfarin-induced skin necrosis may be difficult to differentiate from mimickers, but skin biopsy in conjunction with careful consideration of the clinical history, including time of onset, cutaneous distribution of the lesions, and laboratory findings, are essential for prompt diagnosis and patient treatment. Herein, we review the clinical and histologic features helpful for differentiating warfarin-induced skin necrosis and report a case illustrative of the diagnostic difficulty that may at times be encountered in clinical practice.

Section snippets

Case history

A 79-year-old Venezuelan man with a history of McArdle disease, 36 pack-year former tobacco use, hypertension, and hyperlipidemia, status post-3-vessel coronary artery bypass grafting and aortic valve replacement, presented to our hospital with fatigue and chest discomfort. Admission medications included daily aspirin (81 mg) and warfarin (5 mg) for his mechanical aortic valve. A diagnostic cardiac catheterization procedure via a right femoral venous access site revealed aortic insufficiency

Discussion

Warfarin-induced skin necrosis (WISN) affects 0.01% to 0.1% of patients treated with anticoagulants and more than 200 cases worldwide have been identified to date.1, 8, 9, 10, 11 The first descriptions of this disorder came from the work of McLean12 in 1916 and, later, Flood et al13 in 1943 in the form of “thrombophlebitis migrans disseminata” of the breast.8 Thirteen additional cases were later reported by Verhagen3 in 1954 that identified warfarin as the causative agent of skin necrosis.1, 8

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    Funding sources: None.

    Conflicts of interest: None declared.

    Presented in part at the 44th Annual Meeting of the American Society of Dermatopathology, Baltimore, MD, October 18-21, 2007.

    Reprints not available from the authors.

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