warfarin and Carcinoma--Basal-Cell

Other than the classic skin necrosis induced by oral anticoagulants (OAC) in patients with protein C and S deficiencies, other types of OAC induced-skin ulcers are little known. Herein, we describe an original case of recurrent pyoderma gangrenosum (PG)-like ulcers induced by OAC.. A 70-year-old female heart-transplant recipient presented deep, hyperalgesic and quickly-spreading necrotic ulceration of the right leg 6 weeks after starting oral anticoagulant therapy with fluindione. Histological analysis revealed dermal infiltrate containing polynuclear neutrophils, which accords with the histopathological diagnosis of leukocytoclastic vasculitis or PG. Infectious, autoimmune and thrombophilic causes were ruled out. Fluindione was withdrawn and the ulcer healed completely within a month. Six months later, right leg ulceration recurred two weeks after the patient resumed fluindione but healed within 1 month of discontinuation of the drug. An OAC from another chemical family (warfarin) was then introduced, with further recurrence of ulceration after 2 weeks of treatment.. The chronology of events and the negativity of aetiological explorations allowed a diagnosis to be made of OAC-induced skin ulcer, a rare complication of which the pathophysiology is unclear. This is the first case of PG-like ulcers induced by OAC.

Topics: Aged; Anticoagulants; Bed Rest; Carcinoma, Basal Cell; Diagnosis, Differential; Drug Eruptions; Drug Substitution; Facial Neoplasms; Female; Heart Transplantation; Humans; Hyperalgesia; Molecular Structure; Monoclonal Gammopathy of Undetermined Significance; Phenindione; Postoperative Complications; Pyoderma Gangrenosum; Recurrence; Skin Neoplasms; Skin Ulcer; Thrombophlebitis; Vasculitis, Leukocytoclastic, Cutaneous; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Carcinoma, Basal Cell; Facial Neoplasms; Female; Humans; Mohs Surgery; Postoperative Hemorrhage; Skin Neoplasms; Vitamin K; Warfarin

Many patients who have operations on the head and neck for skin cancer also take warfarin to prevent thromboembolic events, and there is still debate about whether treatment should be continued, adjusted, or temporarily stopped. The main concern is to balance the risk of haemorrhagic and thromboembolic events. In this prospective controlled study we compared bleeding complications in operations for skin cancer of the head and neck between 86 patients who took warfarin (100 tumours) and 87 (100 tumours) who did not. Surgeons of different grades did the operations under the guidance of the same consultant. All those on warfarin had above normal international normalised ratios (INRs) (mean (SD) 2.5 (0.51), mode 2.6, range 1.1-4.0). In the warfarin group 8% of excisions had a bleeding complication compared with 9% in the control group. One patient in each group suffered a severe bleed that required a return to theatre. The difference in tendency to bleed between the groups was not significant (p=0.30), and the site and type of reconstruction did not influence the risk of bleeding significantly. This study shows that patients on warfarin who are within the normal therapeutic range, can be operated on safely for skin cancer by all levels of trained staff.

Topics: Anticoagulants; Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Case-Control Studies; Dermatologic Surgical Procedures; Facial Neoplasms; Follow-Up Studies; Head and Neck Neoplasms; Humans; International Normalized Ratio; Plastic Surgery Procedures; Postoperative Hemorrhage; Prospective Studies; Risk Factors; Safety; Skin Neoplasms; Skin Transplantation; Surgical Flaps; Thromboembolism; Warfarin

We report a patient who developed postoperative bleeding as a result of inadvertent excessive warfarin intake. We subsequently introduced a policy of checking the international normalization ratio (INR) 24 h before cutaneous surgery for all patients on warfarin.. To review the perioperative INR and outcome of all patients on warfarin who had cutaneous surgery from January 1999 to June 2002 at the Department of Dermatology, Sunderland Royal Hospital.. A retrospective review was undertaken from patients' medical records.. Sixty-eight patients (1.84% of total) underwent 85 skin procedures comprising 33 excisions, 16 punch biopsies, 15 curettages, 13 diagnostic biopsies, five shave biopsies, two Mohs micrographic surgical excisions and one delayed reconstruction. Repairs included 50 direct closures, five secondary intention healing, seven local flaps, two full-thickness skin grafts and 20 by electrocautery. Forty-five surgical procedures were undertaken with the INR checked on the day of surgery, 37 procedures within 24 h, and three within 2 days. The preoperative INR ranged from 1.1 to 3.4, median 2.5. There was no excess intraoperative or postoperative bleeding or haematoma for all patients.. Our experience supports the continued and safe use of warfarin for a wide variety of cutaneous surgical procedures with a preoperative INR of < 3.5. We recommend a routine INR before the procedure, preferably within 24 h.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Carcinoma, Basal Cell; Dermatologic Surgical Procedures; Drug Monitoring; Female; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Hemorrhage; Preoperative Care; Retrospective Studies; Skin Neoplasms; Warfarin

Two patients undergoing cutaneous surgery had thromboembolic strokes within 1 week after surgery. Both patients had been taking warfarin for prevention of thromboembolism and warfarin was stopped 3-7 days prior to surgery.. To examine the rationale and problems associated with preoperative warfarin discontinuation.. Review of the medical literature.. When warfarin is stopped prior to surgery and restarted soon after surgery, the patient is at increased risk for thromboembolism. Although it is commonly believed that continuing warfarin during surgery is associated with an increased bleeding risk, for cutaneous surgery, this risk is extremely low and can be easily managed.. Warfarin should not be discontinued prior to cutaneous surgery because of the risk of thromboembolic stroke.

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Brain Infarction; Carcinoma, Basal Cell; Drug Administration Schedule; Eyelid Neoplasms; Female; Humans; Male; Mohs Surgery; Postoperative Complications; Skin Neoplasms; Thromboembolism; Warfarin