Pourdeyhimi N, Bullard Z, et al.
Hospital pharmacy. Date of publication 2014 Dec 1;volume 49(11):1044-8.
1. Hosp Pharm. 2014 Dec;49(11):1044-8. doi: 10.1310/hjp4911-1044.
Warfarin-induced skin necrosis.
Pourdeyhimi N(1), Bullard Z(1).
Author information:
(1)Department of Pharmacy, New Hanover Regional Medical Center , Wilmington,
North Carolina.
BACKGROUND: Warfarin is a frequently used oral anticoagulant in the treatment and
prevention of various medical conditions. One uncommon adverse effect that can
occur following the initiation of therapy is warfarin-induced skin necrosis.
Because it is a rare effect with an undetermined pathophysiology of disease, the
treatment is not well established.
CASE: A 52-year-old female was prescribed warfarin and enoxaparin for a newly
diagnosed deep vein thrombosis (DVT) in the left lower extremity. On day 4 of
therapy, the patient had a supra-therapeutic international normalized ratio
(INR), prompting the discontinuation of enoxaparin and a decrease in the warfarin
dose. The patient returned to the emergency department on day 7 of treatment with
a purple, cold, and extremely painful right foot with punctate areas of necrosis
and petechiae proximal to the discoloration. The patient's INR was found to be
10.64. Following the diagnosis of warfarin-induced skin necrosis, the patient was
administered vitamin K intravenously and fresh frozen plasma (FFP) to reverse the
effects of warfarin and promote protein C and S synthesis. Once the patient's INR
was no longer supratherapeutic, subcutaneous enoxaparin was re-started as
treatment for the known recent DVT. The patient's necrotic foot began to improve
and she was discharged home with an anticipated full recovery.
CONCLUSIONS: Based on the proposed pathophysiology of disease, adequate bridge
therapy may decrease the likelihood of developing this life-threatening
condition. Early recognition and treatment with intravenous vitamin K, FFP or
4-factor prothrombin complex concentrate, and continued wound care are essential
to prevent further complications.
DOI: 10.1310/hjp4911-1044
PMCID: PMC4319805
PMID: 25673894
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