Warfarin Induced Skin Necrosis – Forgotten Diagnosis
Sachin Sondhi*1, Ayushi Mehta2, Kunal Mahajan3
1Department of Cardiology, IGMC Shimla, HP, India
2Department of Anaesthesia, IGMC Shimla, HP, India
3Department of Cardiology, IGMC Shimla, HP, India
Sachin Sondhi, Department of Cardiology, IGMC Shimla, HP, India. Tel: +91-8219508161, E-mail: firstname.lastname@example.org
Sachin Sondhi et al. (2017), Warfarin Induced Skin Necrosis – Forgotten Diagnosis. Int J Car & Hear Heal. 1:1, 2. 10.25141/2575-8160-2017-1.0002
Copyright: ©2017 Sachin Sondhi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are
Received Date: August 16, 2017; Accepted Date: August 21, 2017; Published Date: August 22, 2017
78 year old male presented to us with syncope and was found to
have sick sinus syndrome in form of tachy-brady syndrome with
intermittent atrial fibrillation. After pacemaker implantation,
he was discharged on 3mg of warfarin for prevention of stroke.
At time of discharge his baseline INR was 1.12. After 3 days of
discharge, he developed painful ecchymosis over both lower limbs
which progressed to hemorrhagic bullae and finally to eschar
formation with central necrosis seen within 5 days (Figure 1).
The INR at that time was 1.03. The diagnosis of Warfarin induced
skin necrosis (WISN) was made. His warfarin was stopped for 4
days. After starting local wound care, lesions started improving.
For stroke prevention, finally he was started on dabigatran 110mg
twice a day.
Figure 1. WISN (a) 1st stage of burning painful ecchymotic areas
over bilateral lower limb (b) 2nd stage showing hemorrhagic
bullae (c) 3rd showing characteristic central necrosis
Skin necrosis occurs in 0.01% to 0.1% of patients receiving
warfarin.1 Skin reactions associated with warfarin commonly
occur 3 to 5 days after initiating treatment and are more common
in protein C and protein S deficient patients. Warfarin inactivates
vitamin K-dependent “clotting factors II, VII, IX, and X” and
“natural anticoagulants, Proteins C and Protein S”. The Protein
C and Protein S are inactivated immediately after starting
warfarin because of short half life. This may cause a paradoxical
hypercoagulable milieu in which microthrombi develop in
cutaneous and subcutaneous microvasculature.1-3. This led
to skin necrosis mostly over fatty areas. Treatment involves
discontinuation of warfarin and reversal with vitamin K if needed.
An alternative anticoagulant, such as heparin or LMWH, should
be given to patients with thrombosis. Protein C concentrates may
accelerate healing of skin lesion in protein C deficient patient;
FFP may be value for those with protein S deficiency. Warfarin
should be restarted at low doses with overlapping with parenteral
anticoagulant and should be continued until the INR is in
therapeutic range for at least 2 to 3 consecutive days.
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- Chan YC, Valenti D, Mansfield AO, Stansby G. Warfarin induced
skin necrosis. Br J Surg 2000;87:266 – 72.
- Sallah S, Abdalah JM, Gagnon GA. Recurrent warfarn-induced
skin necrosis in kindreds with protein S deficiency. Haemostasis 1998;28:25 – 30.