warfarin and Skin-Diseases

Hypercoagulable states (HS) are inherited or acquired conditions that predispose an individual to venous and/or arterial thrombosis. The dermatologist can play a vital role in diagnosing a patient's HS by recognizing the associated cutaneous manifestations, such as purpura, purpura fulminans, livedo reticularis, livedo vasculopathy (atrophie blanche), anetoderma, chronic venous ulcers, and superficial venous thrombosis. The cutaneous manifestations of HS are generally nonspecific, but identification of an abnormal finding can warrant a further workup for an underlying thrombophilic disorder. This review will focus on the basic science of hemostasis, the evaluation of HS, the skin manifestations associated with hypercoagulability, and the use of antiplatelet and anticoagulant therapy in dermatology.

Topics: Anetoderma; Anticoagulants; Antiphospholipid Syndrome; Calciphylaxis; Hemostasis; Heparin; Humans; Livedo Reticularis; Necrosis; Platelet Aggregation Inhibitors; Purpura; Skin; Skin Diseases; Thrombophilia; Varicose Ulcer; Venous Thrombosis; Warfarin

Topics: Administration, Oral; Anticoagulants; Benzimidazoles; beta-Alanine; Dabigatran; Drug Contamination; Drug Monitoring; Food-Drug Interactions; Hemorrhage; Heparin; Humans; Hypersensitivity; Injections, Subcutaneous; Necrosis; Osteoporosis; Skin Diseases; Subcutaneous Tissue; Thrombocytopenia; Warfarin

Because calcinosis cutis is a rare syndrome, there is a notable lack of controlled clinical trials on its treatment. The efficacy of calcinosis treatment has only been reported in single cases or small case series. No treatment has been generally accepted as standard therapy, although various treatments have been reported to be beneficial, including warfarin, bisphosphonates, minocycline, ceftriaxone, diltiazem, aluminium hydroxide, probenecid, intralesional corticosteroids, intravenous immunoglobulin, curettage, surgical excision, carbon dioxide laser, and extracorporeal shock wave lithotripsy.

Topics: Biopsy, Needle; Calcinosis; Ceftriaxone; Combined Modality Therapy; Drug Therapy, Combination; Education, Medical, Continuing; Evidence-Based Medicine; Female; Humans; Immunoglobulins, Intravenous; Immunohistochemistry; Laser Therapy; Lasers, Gas; Male; Minocycline; Prognosis; Recurrence; Risk Assessment; Severity of Illness Index; Skin Diseases; Treatment Outcome; Warfarin

Management of perioperative antiplatelet/anticoagulation drugs and appropriate antibiotic prophylaxis for endocarditis are two controversial issues in the safe practice of cutaneous surgery. This article highlights the current best practice based on a literature review on these topics. Antiplatelet agents should be continued perioperatively whenever clinically possible, and discontinued only after consultation with the patient's cardiologist. The exception to this is primary cardiovascular disease, when antiplatelet drugs should be stopped for 1 week before surgery. Warfarin can be continued perioperatively when the international normalised ratio is controlled at < 3. The use of antibiotics in patients at risk of endocarditis has been recently reviewed by the National Institute of Health and Clinical Excellence (NICE), the American Heart Association, and the European Society of Cardiology. The advice has changed significantly over the past few years, and the routine use of antibiotics perioperatively should occur only when there is evidence of infection perioperatively at the site of surgery.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Antibiotic Prophylaxis; Anticoagulants; Aspirin; Calcium Channel Blockers; Clopidogrel; Dipyridamole; Endocarditis, Bacterial; Humans; International Normalized Ratio; Perioperative Care; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Risk Factors; Skin Diseases; Ticlopidine; Warfarin

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.

Topics: Aged; Anticoagulants; Biopsy, Needle; Combined Modality Therapy; Dose-Response Relationship, Drug; Drug Administration Schedule; Follow-Up Studies; Humans; Immunohistochemistry; Male; Necrosis; Severity of Illness Index; Skin Diseases; Warfarin

The frequency of postoperative bleeding and other complications in anticoagulated patients undergoing cutaneous surgery has not been firmly established and consensus on perioperative continuation of treatment is lacking.. The objective was to ascertain the risk of postoperative complications through meta-analysis of data pooled from previously published studies.. A PubMed search (1966-2005) was performed to identify controlled studies reporting bleeding and other complications among patients undergoing cutaneous surgery who were taking anticoagulant medications. Emphasis was placed on prescription anticoagulant medications (aspirin, NSAIDs, warfarin, clopidogrel) and over-the-counter herbal agents with anticoagulant properties.. A total of six studies representing 1,373 patients met criteria for inclusion. Among patients taking aspirin or warfarin, 1.3 and 5.7% experienced a severe postoperative complication, respectively. Patients taking warfarin were nearly seven times as likely to have a moderate-to-severe complication compared to controls (OR, 6.69; 95% CI, 3.03-14.7), a statistically significant difference (p<.001). Patients taking aspirin or NSAIDs were more than twice as likely to have a moderate-to-severe complication compared to controls (OR, 2.0; 95% CI, 0.97-4.13), a strong trend toward statistical significance (p=.06). There were no studies in the literature that examined the effects of combination anticoagulant therapy or the effect of herbal agents on postoperative risk of bleeding.. The results of this meta-analysis suggest that while low, the risk of bleeding among anticoagulated patients may be higher than baseline. Adequately powered prospective studies are required to more carefully delineate the risk of postoperative bleeding and other complications attributable to anticoagulation therapy. Particular emphasis should be placed on examining the effect of combination anticoagulant therapy as well as herbal agents with anticoagulant properties on risk of bleeding after cutaneous surgery.

Topics: Anticoagulants; Aspirin; Fibrinolytic Agents; Humans; Postoperative Hemorrhage; Skin Diseases; Thrombosis; Warfarin

To evaluate the effect of low doses of warfarin in patients with systemic sclerosis with disseminated subcutaneous calcinosis.. Three patients with disseminated subcutaneous calcinosis were treated with low doses of warfarin for 1 year. Subcutaneous calcinotic lesions, coagulation blood parameters, and the tendency for bleeding were followed up during the year.. Two of the patients, who had newly diagnosed, diffuse, and relatively small calcinotic lesions, responded to warfarin treatment, with complete resolution of the calcinosis. The other patient, with larger and longer standing calcinotic lesions, did not respond to warfarin treatment. None of the three patients showed a prolongation of prothrombin time or partial thromboplastin time, nor did any have an increased tendency for bleeding.. Low dose warfarin may serve as an effective treatment for calcinosis in a selected group of patients who have small and relatively new onset calcinosis. This treatment does not prolong the coagulation of blood and there is no increased tendency for bleeding.

Topics: Adult; Aged; Calcinosis; Dermatologic Agents; Drug Administration Schedule; Female; Humans; Scleroderma, Systemic; Skin Diseases; Warfarin

Topics: Anticoagulants; Drug Monitoring; Female; Gastrointestinal Hemorrhage; Humans; Middle Aged; Necrosis; Patient Education as Topic; Skin Diseases; Warfarin

Two patients developed catastrophic multicentric skin necrosis while receiving warfarin to treat venous thromboembolism complicated by immune-mediated heparin-induced thrombocytopenia (HIT). Patient 1 developed skin necrosis involving the breasts, thighs, and face, as well as venous limb gangrene and bilateral hemorrhagic necrosis of the adrenal glands, resulting in death. The second patient developed bilateral mammary necrosis necessitating mastectomies, as well as skin necrosis involving the thigh. Neither patient had an identifiable hypercoagulable syndrome, other than HIT. HIT may represent a risk factor for the development of multicentric warfarin-induced skin necrosis (WISN).

Topics: Adrenal Gland Diseases; Aged; Amputation, Surgical; Anticoagulants; Antigens, Human Platelet; Autoantibodies; Autoimmune Diseases; Databases, Factual; Disseminated Intravascular Coagulation; Ecchymosis; Fatal Outcome; Female; Gangrene; Hemorrhage; Heparin; Humans; Mastectomy; Middle Aged; Multiple Organ Failure; Necrosis; Postoperative Complications; Pulmonary Embolism; Skin; Skin Diseases; Thigh; Thrombin; Thrombocytopenia; Thrombophilia; Thrombophlebitis; Vena Cava Filters; Warfarin

Warfarin-induced skin necrosis is a rare complication of therapy with warfarin or other coumarin derivatives. When it occurs it usually appears 3 to 6 days after initiation of therapy and almost always between days 1 and 10. We report a case of late-onset (16 days after initiation of therapy) warfarin-induced skin necrosis and review the literature on this rarely reported variant of warfarin-induced skin necrosis. The skin lesion in our patient was not associated with either deficiency of protein C or resistance to activated protein C.

Topics: Adult; Anticoagulants; Blood Coagulation Factor Inhibitors; Female; Humans; Male; Middle Aged; Necrosis; Protein C; Skin; Skin Diseases; Thrombosis; Warfarin

Topics: Administration, Oral; Animals; Anticoagulants; Heparin; Humans; Necrosis; Skin; Skin Diseases; Syndrome; Warfarin

Warfarin-induced skin necrosis is a rare but potentially devastating complication of oral anticoagulation. In this article the historical, clinical, and pathophysiologic features of this hypercoagulable event are reviewed, and recommendations for prevention and treatment are discussed.

Topics: Animals; Humans; Necrosis; Skin Diseases; Warfarin

We describe a 57-year-old woman with homozygous protein C deficiency and mild thrombotic manifestations consisting of three spontaneous distal deep vein thromboses occurring after the age of 45. Previous surgery and pregnancies had been uneventful. Low but detectable protein C antigen and activity levels (both 20%) were discovered on the occasion of skin necrosis induced by oral anticoagulation. This therapy was interrupted because of skin necrosis and several episodes of disseminated intravascular coagulation (DIC) at the initiation of treatment despite a cautious protocol. No recurrent thromboembolic event has occurred in our patient using prophylactic doses of low molecular weight heparin for 24 months. New therapeutic approaches might be the administration of low molecular weight heparin or oral anticoagulation associated with protein C replacement in the induction period. This case reflects the variability of expression of protein C deficiency as well as the potential hazards of antivitamin K anticoagulation in this disorder.

Topics: Acenocoumarol; Administration, Oral; Age Factors; Blood Coagulation Disorders; Contraindications; Disseminated Intravascular Coagulation; Drug Therapy, Combination; Female; Genetic Predisposition to Disease; Heparin; Homozygote; Humans; Middle Aged; Necrosis; Protein C Deficiency; Skin; Skin Diseases; Thrombophlebitis; Warfarin

Skin and subcutaneous tissue necrosis is a rare complication of warfarin therapy. Although the incidence is low, with increased use of warfarin family physicians need to be aware of this potentially catastrophic event. This article reviews the history of warfarin necrosis and discusses its clinical presentation. The histologic findings with necrosed lesions are described, with emphasis on the possible pathogenesis of this disorder. Treatment options based on existing clinical experience as outlined in the literature are discussed.

Topics: Humans; Necrosis; Protein C; Skin Diseases; Warfarin

Warfarin-induced skin necrosis is a rare but serious complication of oral anticoagulant therapy. This condition has been associated with protein C deficiency but only rarely reported in patients with a deficiency of protein S. We have managed 2 patients with a history of warfarin-induced skin necrosis who were diagnosed as being protein-S-deficient. Since both patients were candidates for long-term anticoagulant therapy we elected to reintroduce warfarin using a regimen designed to minimize the risk of recurrent skin necrosis. While they were therapeutically anticoagulated with heparin, warfarin was started at 1 mg/day and the dose was increased gradually. Heparin was not discontinued until the prothrombin times were in the therapeutic range for at least 72 h. Both patients tolerated the reinstitution of warfarin without difficulty and they have now been followed for over 2 years on oral anticoagulants without complication.

Topics: Adult; Combined Modality Therapy; Female; Heparin; Humans; Male; Necrosis; Phenindione; Protein S Deficiency; Skin; Skin Diseases; Skin Transplantation; Thrombophlebitis; Warfarin

The sudden development of cyanotic lesions on the feet may be a result of atheroembolic disease or a number of medical conditions. A careful history and physical examination, basic laboratory tests, and noninvasive vascular assessment usually distinguish between medical and surgical causes and direct the choice of further investigations. Specific therapy is often available for medical conditions causing this syndrome. The management of atheroembolic disease is more controversial. In particular, further research is necessary to determine which patients need surgical intervention and which patients can be managed safely by medical therapy.

Topics: Adrenal Cortex Hormones; Blood Coagulation Disorders; Calcinosis; Cyanosis; Embolism; Humans; Ischemia; Postoperative Complications; Skin Diseases; Syndrome; Toes; Vasculitis; Warfarin

Two cases of necrosis of skin and subcutaneous tissues in patients taking oral anticoagulants are reported, and the English literature is reviewed. The mechanism of coumarin necrosis remains unknown. Most patients are women and the lesions are most common on the abdomen, buttocks, thighs, and breasts. Simple mastectomy is the usual treatment for a breast lesion. Although some cases have been reported in which the skin lesion has healed despite continued anticoagulant therapy, curtailing its use is recommended. Heparin has not been associated with skin necrosis, however, and may be desirable if continued anticoagulant treatment is necessary.

Topics: Anticoagulants; Breast Diseases; Coumarins; Female; Heparin; Humans; Male; Mastectomy; Middle Aged; Necrosis; Skin Diseases; Warfarin

Many patients undergoing surgical procedures take medications that influence the coagulation system. It is common practice to discontinue the use of aspirin and warfarin products 7 to 10 days before any major surgical procedure. However, there is some controversy as to whether these medications should be discontinued for minor dermatological procedures. Our aim was to study the incidence of complications in patients receiving aspirin or warfarin and undergoing minor dermatological procedures. Two thousand three hundred twenty-six patients, operated on by a single surgeon, were studied for complications. Warfarin was used by 28 patients, 228 took aspirin, and the remainder took neither. There was no difference in the complication rate among the three groups as long as the surgeon diligently obtained hemostasis. It appears that patients taking aspirin or warfarin do not need to discontinue these medications before minor dermatological procedures.

Topics: Aged; Anticoagulants; Aspirin; Female; Follow-Up Studies; Humans; Incidence; Male; Middle Aged; Postoperative Hemorrhage; Prospective Studies; Skin Diseases; Surgical Wound Dehiscence; Warfarin

Topics: Anticoagulants; Chi-Square Distribution; Heparin; Humans; Skin Diseases; Statistics, Nonparametric; Surgical Procedures, Operative; Treatment Outcome; Warfarin

Patients with calcinosis universalis secondary to dermatomyositis or systemic sclerosis have increased levels of the calcium-binding amino acid, gamma-carboxyglutamic acid. The enzyme that effects gamma carboxylation of glutamic acid is warfarin-sensitive. Four patients with calcinosis universalis were treated with 1 mg per day of warfarin for 18 months in a non-blind initial study. Two patients had both decreased gamma-carboxyglutamic acid urinary concentration and decreased extra-skeletal uptake on technetium 99m-diphosphonate whole-body nuclear scanning. In a subsequent double-blind placebo study, two thirds of the patients receiving 1 mg per day of warfarin had decreases in extra-skeletal nuclear tracer uptake after 18 months, compared with none of the four patients receiving placebo. No patient had a change in clinical assessment, bleeding complication, or baseline normal prothrombin time. This low-dose warfarin regimen appears to have no demonstrable adverse effects, and these results suggest a beneficial effect on the progression of calcinosis in these rheumatic diseases.

Topics: Bone and Bones; Calcinosis; Dermatomyositis; Double-Blind Method; Drug Evaluation; Humans; Radiography; Radionuclide Imaging; Random Allocation; Scleroderma, Systemic; Skin Diseases; Time Factors; Warfarin

Topics: Anticoagulants; Humans; Necrosis; Skin; Skin Diseases; Warfarin

Topics: Adolescent; Female; Humans; Necrosis; Protein C; Protein C Deficiency; Rivaroxaban; Secondary Prevention; Skin Diseases; Thrombin; Thrombomodulin; Warfarin

Patients with protein C deficiency are at increased risk for thrombolic diseases. Non-vitamin K antagonist anticoagulant options should be considered in patients with warfarin-induced skin necrosis (WISN) in the setting of protein C. We report a 41-year-old African American male patient with WISN and protein C deficiency who was treated with rivaroxaban followed by dabigatran. After 1 month on rivaroxaban, he began experiencing blood in his stools, unrelenting pain in his lower extremities, found it difficult to obtain medication despite having insurance and as a result did not maintain compliance. He was then assessed at the hospital, symptomatically treated and discharged on dabigatran. After 6 weeks, he reported symptomatic relief and less side effects. This case involved a head-to-head clinical comparison of rivaroxaban and dabigatran as alternatives to warfarin anticoagulation therapy.

Topics: Adult; Anticoagulants; Diagnosis, Differential; Humans; Male; Necrosis; Protein C Deficiency; Skin Diseases; Venous Thromboembolism; Warfarin

Topics: Aged; Anticoagulants; Drug Substitution; Factor Xa Inhibitors; Humans; Kidney Diseases; Male; Necrosis; Rivaroxaban; Skin; Skin Diseases; Warfarin; Wound Healing

Warfarin-induced skin necrosis (WISN) is a rare complication of anticoagulant therapy associated with a high incidence of  morbidity and mortality requiring immediate drug cessation. At particular risk are those with various thrombophilic abnormalities, especially when warfarinisation is undertaken rapidly with large loading doses of warfarin. Cutaneous findings include petechiae that progress to ecchymosis and hemorrhagic bullae. With the increasing number of patients anticoagulated as out-patients for thromboprophylaxis, we are concerned that the incidence of skin necrosis may increase. We present a case of WISN with low protein C level. He was a 50-year-old male who came to our department because of acute infarction in irrigation area of the superior cerebellar artery. He had intermittent atrial fibrillation and was started on anticoagulant therapy.  After few day of therapy, he developed skin necrosis, and his level of protein C was low. Warfarin-induced skin necrosis is a rare but serious complication that can be prevented by routine screening for protein C, protein S or antithrombin deficiencies or for the presence of antiphospholipid antibodies before beginning warfarin therapy.

Topics: Anticoagulants; Humans; Male; Middle Aged; Necrosis; Protein C Deficiency; Skin Diseases; Warfarin

Topics: Anticoagulants; Calciphylaxis; Debridement; Disease Progression; Fat Necrosis; Female; Humans; Middle Aged; Skin Diseases; Warfarin

Topics: Anticoagulants; Antithrombins; Benzimidazoles; beta-Alanine; Dabigatran; Diagnosis, Differential; Humans; Ischemic Attack, Transient; Male; Middle Aged; Necrosis; Skin; Skin Diseases; Thrombosis; Warfarin

An 85-year-old man on warfarin for atrial fibrillation presented with skin bleeding. International normalised ratio (INR) and activated partial thromboplastin time (APTT) were elevated and did not correct even after warfarin reversal with vitamin K, prothrombin complex concentrate (PCC) and fresh frozen plasma. Mixing coagulation studies with normal plasma suggested the presence of an inhibitor rather than the multiple coagulation factor deficiencies expected with warfarin. Assays of the common-pathway coagulation factors revealed factor V concentration <2% with inhibitor level elevated to 11 Bethesda units. The bleeding resolved following a course of corticosteroids. Coagulation studies and factor V level returned to normal along with resolution of the inhibitor. We report the case of the diagnostic dilemma posed and successful therapy implemented despite the limited evidence-based data being available for the treatment of this rare condition.

Topics: Aged, 80 and over; Atrial Fibrillation; Blood Coagulation Disorders; Factor V; Glucocorticoids; Hemorrhage; Humans; Male; Prednisolone; Skin Diseases; Warfarin

Topics: Aged, 80 and over; Amputation, Surgical; Anticoagulants; Hand; Humans; Leg; Male; Necrosis; Scrotum; Skin Diseases; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Diagnosis, Differential; Fatal Outcome; Female; Humans; Necrosis; Skin Diseases; Warfarin

Topics: Aged; Anterior Wall Myocardial Infarction; Biopsy, Needle; Clopidogrel; Follow-Up Studies; Humans; Immunohistochemistry; Lupus Coagulation Inhibitor; Male; Platelet Aggregation Inhibitors; Polyarteritis Nodosa; Risk Assessment; Skin Diseases; Ticlopidine; Treatment Outcome; Warfarin

Necrotic skin lesions are unfortunately common in patients with end stage renal disease undergoing dialysis therapy. We present a case of a necrotic skin lesion in a peritoneal dialysis patient shortly after the initiation of warfarin therapy for atrial fibrillation. We discuss and contrast distinguishing features of two diagnostic possibilities: warfarin skin necrosis (WSN) and calcific uremic arteriopathy (CUA) in terms of clinical presentation, risk factors and pathology. Lastly, we outline the importance of establishing a diagnosis as treatment regimens differ substantially.

Topics: Anticoagulants; Calciphylaxis; Diabetic Nephropathies; Diagnosis, Differential; Humans; Kidney Failure, Chronic; Male; Middle Aged; Necrosis; Skin Diseases; Warfarin

Topics: Anticoagulants; Chest Pain; Coloring Agents; Drug Hypersensitivity; Drug-Related Side Effects and Adverse Reactions; Humans; Male; Middle Aged; Skin Diseases; Warfarin

A case of warfarin-induced skin necrosis (WISN) treated with protein C concentrate (human) is reported.. A 46-year-old Caucasian woman was admitted to the hospital for a herpes viral infection complicated by neutropenic fevers of unknown origin. Broad-spectrum antibiotics were initiated, as well as enoxaparin for prophylaxis of deep venous thrombosis. By hospital day 7, the patient's platelets decreased by 50%; by hospital day 8, they decreased another 50%. A test for heparin antibody was positive, and enoxaparin was stopped. Two days later, the patient developed a clot in her peripherally inserted central catheter, and warfarin and argatroban were initiated. Within 24 hours of warfarin initiation, the patient developed swelling in her feet and new lesions on her inner thigh, buttock, face, feet, fingers, and arms. She was treated with phytonadi-one and fresh frozen plasma, but these treatments failed to slow the progression of her lesions, which had turned to necrotic tissue. WISN was suspected, and warfarin therapy was discontinued after three doses. After a consultation with a hematologist, treatment with protein C concentrate (human) was initiated. Within 24 hours of treatment with this product, progression of necrosis stopped, and the patient's respiratory failure resolved. The patient underwent multiple skin grafts, and the lesions healed without extensive scarring. She experienced no adverse effects with the administration of protein C concentrate (human).. A patient with WISN was treated with protein C concentrate (human) with overall good results and no adverse effects.

Topics: Anticoagulants; Female; Humans; Middle Aged; Necrosis; Protein C; Respiratory Insufficiency; Skin; Skin Diseases; Skin Transplantation; Warfarin

Warfarin-induced skin necrosis is a rare but recognised complication of this drug. The condition predominantly affects the breasts, buttocks and thighs of obese, peri-menopausal women. We present the case of a patient with the condition in an unusual site, and we discuss the management challenges involved.. An 82-year-old man presented to the ENT department with a diagnosis of pinna haematoma. There was no history of trauma or infection. The patient was taking warfarin long-term for recurrent deep vein thrombosis. Two weeks prior to admission, the patient had had a loading course of warfarin following surgery. Multiple clinical teams were involved in treatment. The only abnormal laboratory investigation was a low protein S level; biopsy showed skin necrosis.. In this case, the unusual presentation created diagnostic confusion, and may have precipitated aggressive surgical debridement. However, a more conservative management strategy was used, which we would recommend in future.

Topics: Aged, 80 and over; Anticoagulants; Ear Auricle; Humans; Male; Necrosis; Skin; Skin Diseases; Warfarin

The risk of haemorrhage from minor cutaneous surgical procedures has long been a concern in the treatment of patients receiving warfarin as anti-coagulation therapy. Interruption, alteration, hospital admission and monitoring have resource implications as well as the potential for complications. Therefore, we wanted to determine whether it was feasible to undertake typical minor plastic surgery procedures without altering patients' warfarin dosage regimens. We undertook a prospective study of 51 patients (age range 36 to 86), with 78 wounds, undergoing a range of minor cutaneous surgical procedures including excision biopsies, local flaps and skin grafts. The patients continued their normal warfarin regimen and the INR was checked on the day of surgery, ranging from 1.1 to 4.0. There were no problems encountered during surgery, but two patients presented with bleeding from a wound a few days post-operatively. We feel that it is unnecessary to modify warfarin regimens for minor cutaneous surgery. However, a well-briefed patient and experienced surgical management with good support facilities are a prerequisite for this.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Cohort Studies; Female; Humans; Male; Middle Aged; Postoperative Complications; Skin Diseases; Warfarin

Topics: Anticoagulants; Female; Humans; Male; Middle Aged; Protein C; Protein C Deficiency; Protein S; Protein S Deficiency; Skin; Skin Diseases; Skin Diseases, Vascular; Warfarin

A 64-year-old woman with colon carcinoma presented with subsegmental pulmonary emboli. Platelet count on presentation was 598 x10(9)/l. The patient was anticoagulated with intravenous heparin. By hospital day 3, heparin was replaced with enoxaparin and warfarin. On hospital day 6, the patient developed a 20 x 15 cm area of necrotic skin on her left hip and a 1 x 3 cm area of necrosis on her right hip. By that time, her platelet count had fallen to 433 x 10(9)/l. Three days later (hospital day 9), anticoagulation was switched from the combination of enoxaparin and warfarin to argatroban. Her platelet count reached a nadir of 82 x 10(9)/l by the 12th hospital day. The areas of skin necrosis had never been sites of heparin injection. Heparin/platelet factor 4 antibody, sent on hospital day 9, returned positive and (14)C-serotonin release assay was also positive. This case illustrates that processes underlying heparin-induced thrombocytopenia (HIT) may also underlie warfarin-induced skin necrosis. Skin necrosis may be the earliest manifestation of HIT and need not be accompanied by thrombocytopenia. This patient's course illustrates that HIT should be considered in all patients presenting with skin necrosis while receiving anticoagulation with heparin or a combination of heparin and warfarin.

Topics: Colonic Neoplasms; Female; Heparin; Humans; Middle Aged; Necrosis; Pulmonary Embolism; Skin Diseases; Thrombocytopenia; Warfarin

Hemodialysis complicated by heparin-induced thrombocytopenia (HIT) is a rare event requiring anticoagulation with direct-thrombin inhibitors. Contaminant calcific uremic arteriolopathy (calciphylaxis) further complicates this situation due to the possibility that warfarin anticoagulation may exacerbate skin necrosis. The authors report a patient with renal failure and calciphylaxis who developed HIT after starting hemodialysis. She was successfully treated with Argatroban.

Topics: Adult; Anticoagulants; Arginine; Calciphylaxis; Drug Contamination; Female; Heparin; Humans; Necrosis; Pipecolic Acids; Renal Dialysis; Renal Insufficiency; Skin Diseases; Sulfonamides; Thrombocytopenia; Warfarin

Percutaneous toxicity of anticoagulant rodenticides is usually manifested by coagulopathy and/or fatal outcome. There are, however, virtually no data on other biological effects of this class of pesticides that gain access into the organism via skin. In this study, percutaneous toxicity of epicutaneously applied warfarin was evaluated by measuring changes in peripheral blood granulocytes in rats. Application of 10 mug (0.05 mg/kg) or 100 mug (0.5 mg/kg) of warfarin (WF) for 3 consecutive days resulted in an increase in prothrombin time, documenting the access of warfarin to systemic circulation. Application of warfarin led to an increase in relative numbers of granulocytes at higher dose, whereas both doses resulted in increased metabolical viability, evaluated by 3-(4, 5-dimethyl-2-thiazolyl)-2, 5-diphenyl-2H-tetrazolium bromide (MTT) reduction assay. Higher warfarin dose resulted in both granulocyte activation and priming (evaluated by cytochemical nitroblue tetrazolium, NBT, reduction assay of respiratory burst), whereas only a tendency toward activation was noted at lower WF dose. Soluble mediators from the circulation seem responsible for the observed effects, as exogenous plasma from WF-treated animals stimulated NBT reduction by isologous or naïve granulocytes. Data presented in this study are relevant for the recognition of biological effects, other than those affecting hemostasis, of anticoagulant rodenticides that gain access to systemic circulation through the skin.

Topics: Administration, Cutaneous; Animals; Anticoagulants; Blood Coagulation; Cell Survival; Cells, Cultured; Dose-Response Relationship, Drug; Granulocytes; Leukocyte Count; Male; Prothrombin Time; Rats; Respiratory Burst; Rodenticides; Skin Diseases; Warfarin

Topics: Aged; Anticoagulants; Diagnosis, Differential; Female; Follow-Up Studies; Humans; Necrosis; Outpatients; Patient Discharge; Pulmonary Embolism; Skin; Skin Diseases; Warfarin

Topics: Anticoagulants; Calciphylaxis; Diabetes Mellitus, Type 2; Female; Humans; Leg Dermatoses; Middle Aged; Skin Diseases; Treatment Outcome; Warfarin

Topics: Aged; Anticoagulants; Female; Humans; Necrosis; Skin Diseases; Warfarin

The perioperative management of anticoagulation and antiplatelet therapy is a controversial topic in the field of dermatologic surgery. Dermasurgeons must weigh the risk of bleeding against the risk of thrombotic complications when deciding how to manage perioperative anticoagulation.. Our aim is to present a summary of current practice in anticoagulation management perioperatively during cutaneous surgery. We compare our results to those found in a similar survey in 2002.. A questionnaire surveying current practice in perioperative management of anticoagulant therapy was mailed to 720 dermasurgeons.. Thirty-eight percent of dermasurgeons responded to the questionnaire. Of the responding physicians, 87% discontinue prophylactic aspirin therapy, 37% discontinue medically necessary aspirin, 44% discontinue warfarin, 77% discontinue nonsteroidal anti-inflammatory drugs (NSAIDs), and 77% discontinue vitamin E therapy perioperatively at least some of the time. Although clopidogrel was not surveyed, 78 physicians included comments about the management of this agent.. Dermasurgeons were more likely to continue medically necessary aspirin and warfarin in 2005 compared to 2002, with the most dramatic shift evident in the management of warfarin. They were more likely to discontinue prophylactic aspirin, NSAIDs, and vitamin E. Surgeons were concerned about bleeding with the antiplatelet agent clopidogrel. More evidence-based medicine is necessary to set guidelines for the management of anticoagulation and antiplatelet therapy perioperatively.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Clopidogrel; Dermatology; Drug Utilization Review; Humans; Mohs Surgery; Perioperative Care; Practice Patterns, Physicians'; Skin Diseases; Surveys and Questionnaires; Ticlopidine; United States; Vitamin E; Warfarin

Although the overall incidence is low, bleeding complications in dermatologic surgery can occur and be the source of significant patient morbidity. In this article, we summarize the key aspects of preoperative assessment of patients at risk for bleeding. A review of current issues and literature regarding safe continuation of anticoagulant and antiplatelet medications in dermatologic surgery patients is also presented. In addition, principles for management of bleeding events, should they occur, are also highlighted.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Clopidogrel; Humans; Intraoperative Complications; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Preoperative Care; Skin Diseases; Ticlopidine; Warfarin

Topics: Arterial Occlusive Diseases; Humans; Skin Diseases; Thrombocytopenia; Warfarin

Warfarin-induced skin necrosis is an unusual complication of anticoagulation therapy associated with high morbidity. A patient is presented who had protein C deficiency and in whom this complication developed twice within a short time as a result of delayed diagnosis. Early recognition of this syndrome has important implications in the treatment of such patients and may reduce the severity of complications.

Topics: Adult; Arterial Occlusive Diseases; Humans; Male; Necrosis; Protein C Deficiency; Skin Diseases; Thrombosis; Warfarin

Warfarin-induced skin necrosis (WISN) is a disorder of unclear etiology that predominantly affects obese women. Although WISN typically occurs within the first 10 days of warfarin therapy, some patients develop the complication several years after warfarin exposure. We describe the case of a 43-year-old Caucasian woman with a history of recurrent thromboembolic disorders, protein S deficiency, and multiple exposures to warfarin who came to the emergency room with complaints of worsening dermatitis that had progressed over a 15-hour period. Examination revealed multiple, diffuse "lace-like" erythematous eruptions with superimposed lesions that were tender, ulcerated, and crusted. A biopsy was performed, and histopathologic findings were consistent with WISN. Based on the Naranjo adverse drug reaction probability scale, a probable causal relationship existed between warfarin and skin necrosis in this patient. Since treatment is generally supportive, prompt and prudent evaluation of suspicious skin lesions is necessary to prevent the serious sequelae associated with WISN.

Topics: Adult; Anticoagulants; Fatal Outcome; Female; Humans; Necrosis; Skin; Skin Diseases; Warfarin

Topics: Anticoagulants; Humans; Male; Middle Aged; Necrosis; Priapism; Protein C Deficiency; Risk Factors; Skin Diseases; Warfarin

Warfarin-induced skin necrosis is a rare complication associated with the use of oral anticoagulants. Most patients develop this at the initiation of therapy, often while still receiving intravenous unfractionated heparin (UFH). Recently, low-molecular-weight heparins (LMWHs) have gained wider use, providing an option for outpatient treatment of deep-vein thrombosis. The treatment protocols are similar to UFH, including the early initiation of oral anticoagulation with warfarin. A Medline search failed to reveal any cases of warfarin-induced skin necrosis while using a LMWH. We present a patient with protein S deficiency who developed warfarin skin necrosis despite appropriate anticoagulation with enoxaparin, and review the chemical and clinical difference between UFH and LMWH.

Topics: Anticoagulants; Arterial Occlusive Diseases; Enoxaparin; Female; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Middle Aged; Necrosis; Popliteal Artery; Postoperative Complications; Protein S Deficiency; Skin Diseases; Subclavian Vein; Tibial Arteries; Treatment Failure; Vascular Surgical Procedures; Venous Thrombosis; Warfarin

To report widespread cutaneous lesions due to low-molecular-weight heparin therapy associated with heparin-induced thrombocytopenia (HIT), but without evidence of thrombocytopenia, and to review previously reported cases of skin reactions related to heparin therapy.. A 59-year-old white man with a subtotally resected glioblastoma developed febrile neutropenia and pneumonia secondary to chemotherapy. The development of an upper extremity thrombosis, following insertion of a peripherally inserted central venous catheter, was treated with subcutaneous dalteparin. Cutaneous lesions developed distant from the site of injection. The diagnosis of HIT was confirmed despite stable platelet counts. Dalteparin therapy was discontinued immediately, and anticoagulation was maintained with warfarin. The skin lesions resolved without further complications.. Numerous cases of heparin-induced cutaneous reactions have been reported. The majority of these describe a local reaction at the heparin injection site with or without associated thrombocytopenia. The case presented here is unique in that the observed skin reaction was distant to the injection site and occurred without thrombocytopenia, but with detectable heparin-dependent antibodies.. Although a skin reaction is a rare complication of heparin therapy, it can be a clinical indicator of HIT despite normal platelet counts. Patients who develop skin lesions should have their heparin therapy discontinued and a diagnosis of HIT investigated.

Topics: Antibodies; Dalteparin; Humans; Male; Middle Aged; Skin; Skin Diseases; Thrombocytopenia; Warfarin

Topics: Anticoagulants; Female; Humans; Middle Aged; Necrosis; Skin Diseases; Venous Thrombosis; Warfarin

A 34-year-old woman with systemic lupus erythematosus and high titres of antiphospholipid antibodies was admitted to hospital suffering a viral illness but developed haemorrhagic and necrotic areas on the neck and anterior chest 7 days following cessation of warfarin. Anticoagulation had been initiated following a retinal vein thrombosis, but was ceased on day 4 of admission when she was found to be excessively anticoagulated (international normalized ratio (INR) > 10). However, at the time of developing the cutaneous lesions, the INR was sub-therapeutic. Histology of a skin biopsy from the neck revealed thrombosis of upper dermal blood vessels without vasculitis, consistent with antiphospholipid antibody-related skin necrosis. This case illustrates one of the cutaneous features that can occur in patients with elevated titres of antiphospholipid antibodies and the importance of closely monitoring anticoagulation in such patients.

Topics: Adult; Antibodies, Antiphospholipid; Anticoagulants; Antiphospholipid Syndrome; Biopsy, Needle; Drug Therapy, Combination; Female; Follow-Up Studies; Heparin; Humans; Immunohistochemistry; Lupus Erythematosus, Systemic; Neck; Necrosis; Risk Assessment; Severity of Illness Index; Skin Diseases; Treatment Outcome; Warfarin

Thrombotic events are rare complications during anticoagulation therapy. The thrombosis varies from localized cutaneous involvement to catastrophic thromboembolism and is usually associated with an underlying thrombophilia. We describe a patient who developed skin necrosis during warfarin treatment for a pulmonary thromboembolism. The management was complicated by the development of heparin-induced thrombocytopenia and further thrombotic events. Thrombophilia screen demonstrated the presence of protein S deficiency and Factor V Leiden as the prothrombotic factors, together with the demonstration of antiplatelet factor 4 antibodies, which confirms the diagnosis of heparin-induced thrombocytopenia (type II). Reinstitution of warfarin at a low loading dose was successful without the recurrence of skin lesions nor any further thrombosis.

Topics: Adult; Anticoagulants; Autoantibodies; Factor V; Female; Humans; Necrosis; Platelet Count; Platelet Factor 4; Protein S Deficiency; Purpura, Thrombocytopenic; Skin; Skin Diseases; Thrombophilia; Warfarin

A large subcutaneous hematoma extending from the left axillary region to the left flank developed in a 70-year-old man receiving anticoagulant therapy. The cause was repeated microtrauma caused by the axillary pad on a walker. Physicians and physiotherapists should be aware that rehabilitation devices causing pressure on the skin increase hemorrhagic risk in patients taking anticoagulants. Accordingly, these patients should systematically be checked for hemorrhagic complications, and the use of such devices should be limited.

Topics: Aged; Anticoagulants; Ecchymosis; Equipment Design; Hematoma; Hemorrhage; Humans; Male; Pressure; Risk Factors; Skin; Skin Diseases; Walkers; Warfarin

Topics: Adult; Anticoagulants; Female; Humans; Necrosis; Puerperal Disorders; Skin; Skin Diseases; Thrombophlebitis; Treatment Refusal; Warfarin

Warfarin-induced skin necrosis is a rare and dangerous complication affecting 0.01-0.1% of patients on warfarin. Deficiencies in protein C or protein S in association with other factors have been implicated in its etiology. No report has described this disorder in the immediate postpartum period in patients with protein S deficiency.. A 1-week postpartum woman with known protein S deficiency presented with skin necrosis after a previously uneventful course of warfarin.. Reduced levels of free protein S during the antepartum and immediate postpartum periods predispose protein S-deficient women to warfarin skin necrosis. Previously uncomplicated courses of warfarin do not obviate the possibility of skin necrosis with future warfarin administrations. Initiation of low-dose warfarin with heparin can reduce the likelihood of this disorder.

Topics: Adult; Anticoagulants; Female; Humans; Necrosis; Postpartum Period; Pregnancy; Protein S Deficiency; Skin; Skin Diseases; Warfarin

Skin necrosis is a rare but serious complication of oral anticoagulation with coumarin derivatives. Frequently, the necrosis can be extensive and may result in major morbidity and mortality. The majority of these patients require prolonged anticoagulation for life-threatening conditions such as deep various thrombosis and pulmonary embolism. Resuming oral anticoagulants in the face of skin necrosis is a difficult decision for both the patient and the physician. Because long-term heparin therapy is inconvenient and is associated with significant side effects, we reviewed the literature to find alternative treatment strategies. A Medline search was done, and all papers published in English since 1967 were reviewed. Of 58 cases with skin necrosis attributed to oral anticoagulants, oral anticoagulation was resumed in 7 patients with no resulting adverse effects. Warfarin is the most widely used coumarin derivative in the United States. Based on our review, we make recommendations for resuming warfarin in patients who have developed skin necrosis when the clinical condition absolutely requires prolonged anticoagulation.

Topics: Adult; Anticoagulants; Female; Humans; Male; Middle Aged; Necrosis; Skin Diseases; Warfarin

We describe the use of low doses of warfarin to treat calcinosis in a patient with systemic sclerosis or CREST syndrome. Our patient had Raynaud's phenomenon, skin sclerosis of the neck and the distal surface of the elbows, and pitting ulcers and scarification of the fingers as well as cutaneous calcinosis. After beginning warfarin, no calcium containing substance was discharged from the fingertip ulcers. There was no tendency to bleed and activated partial thromboplastin time and prothrombin time were normal. Sequential radiographs of the hands showed that calcinosis had improved. Since there seem to be few adverse effects, the use of warfarin in patients with calcinosis warrants further study.

Topics: Calcinosis; Dose-Response Relationship, Drug; Female; Hand; Humans; Middle Aged; Partial Thromboplastin Time; Prothrombin Time; Radiography; Scleroderma, Systemic; Skin Diseases; Warfarin

Topics: Administration, Oral; Adult; Female; Humans; Necrosis; Skin; Skin Diseases; Warfarin

Induration is a prominent feature of delayed hypersensitivity reaction (DHR), and fibrin deposition is the central mechanism. We studied the effects of two inhibitors of DHR on the activities of thrombin and plasmin in the extract of the skin site of DHR and compared the two activities in the site of DHR with those in the site of the Arthus reaction (AR) that lacks induration. Warfarin, an anticoagulant, inhibited thrombin activity and induration, but not plasmin activity. Ferritin, a blocker of a macrophage-dependent reaction, inhibited the two activities and induration. The lesion of DHR had three to four times the thrombin activity of the lesion of AR, and the activity paralleled the development of induration. In contrast, plasmin activity of the site of DHR was lower than that of the site of AR and was associated with the reduction of induration. The two protease activities in the site of AR did not correlate with the development of the AR lesion. These results suggest that thrombin and plasmin mediate the development of induration and that induration is produced by a synergistic effect of high thrombin activity and low plasmin activity in the site of DHR.

Topics: Amino Acid Sequence; Animals; Female; Ferritins; Fibrinolysin; Guinea Pigs; Hypersensitivity, Delayed; Male; Molecular Sequence Data; Skin Diseases; Thrombin; Warfarin

Topics: Aged; Female; Heparin; Humans; Middle Aged; Necrosis; Skin Diseases; Thrombophlebitis; Warfarin

Skin necrosis is a well-known yet rare complication of oral anticoagulant therapy. We report the unusual recurrence of lesions typical of warfarin skin necrosis in the absence of anticoagulant therapy. A 59-year-old woman developed skin necrosis while receiving prophylactic warfarin following the detection of a large left ventricular thrombus. The warfarin was discontinued and the lesions improved. One month later new areas of skin necrosis developed although the patient had received no further warfarin. Progressive congestive heart failure, poor nutrition, and prolonged oral antibiotic therapy preceded the recurrence. Vitamin K deficiency was present on admission. The potential role of vitamin K-dependent coagulation factors in the pathogenesis of anticoagulant-associated skin necrosis is discussed.

Topics: Female; Humans; Middle Aged; Necrosis; Skin Diseases; Vitamin K Deficiency; Warfarin

Coumarin skin necrosis is a rare and usually unpredictable complication of coumarin therapy, occasionally leading to death. Onset is usually between the third and sixth day of coumarin therapy. The patient most commonly complains of pain in a region of abundant subcutaneous fat, with progression to erythema, petechiae, and gangrenous necrosis. Thrombosis of the dermal and the subcutaneous veins is demonstrated pathologically. We describe a case and review the pathogenesis, treatment, and prevention of this lesion.

Topics: Aged; Aged, 80 and over; Biopsy; Diagnosis, Differential; Female; Humans; Necrosis; Skin Diseases; Thrombosis; Warfarin

Anticoagulation instability due to a change in intake of vitamin K after dietary modification was observed in 2 patients on long-term oral anticoagulants. One patient developed diffuse bruises treated conservatively with fresh frozen plasma transfusion and the other had a thrombosed aortic prosthesis which required emergency operation. To prevent such complications, dietary modification especially with food rich in vitamin K should be undertaken with care in patients on long-term oral anticoagulants.

Topics: Adult; Aortic Valve; Blood Coagulation; Diet; Drug Interactions; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Skin Diseases; Thrombosis; Vitamin K; Vitamin K Deficiency; Warfarin

Topics: Drug Interactions; Hemorrhage; Humans; Male; Middle Aged; Skin Diseases; Stanozolol; Warfarin

Topics: Aged; Epoprostenol; Female; Humans; Necrosis; Skin; Skin Diseases; Warfarin

Topics: Adult; Heparin; Humans; Male; Necrosis; Skin; Skin Diseases; Warfarin

Topics: Adult; Blood Transfusion; Drug Therapy, Combination; Glycoproteins; Hemorrhage; Heparin; Humans; Male; Necrosis; Plasma; Protein C; Skin Diseases; Thromboembolism; Warfarin

Topics: Adult; Antigens; Blood Proteins; Factor X; Female; Glycoproteins; Heterozygote; Humans; Male; Necrosis; Penile Diseases; Protein C; Skin Diseases; Vitamin K 1; Warfarin

Topics: Aged; Female; Humans; Leg; Male; Middle Aged; Necrosis; Purpura; Skin Diseases; Warfarin

Topics: Adult; Female; Humans; Necrosis; Skin Diseases; Warfarin

Gangrene of the male external genitalia is an uncommon urologic problem with a limited differential diagnosis. To the etiologic spectrum we add warfarin-induced penile gangrene. Pathophysiology, diagnosis and treatment are discussed.

Topics: Adult; Humans; Male; Necrosis; Penile Diseases; Skin Diseases; Thrombophlebitis; Warfarin

Skin necrosis secondary to Coumadin-congener therapy is a rare, unpredictable complication. A case is reported of a patient given sodium warfarin therapy following coronary artery bypass who developed skin necrosis of the trochanteric region, bilaterally, and the right breast on the fourth day following administration of Coumadin. The Coumadin therapy was discontinued, and the areas of skin necrosis went on to slow, spontaneous healing. However, significant subcutaneous induration persisted, although the areas were no longer painful.

Topics: Breast; Diagnosis, Differential; Female; Hemorrhage; Hip; Humans; Middle Aged; Necrosis; Skin; Skin Diseases; Warfarin

Four cases of warfarin-induced skin necrosis are reported, and previous reports of this adverse drug reaction are summarized. A 53-year-old man experienced two episodes of skin necrosis on his left flank and buttock, following the initiation of warfarin therapy for acute thrombophlebitis and after a dose adjustment. The lesion formed multiple hemorrhagic bullae that ruptured, and an eschar formed that did not heal and eventually required skin grafting. Seven days after the initiation of warfarin therapy, an area of erythema surrounded by a halo was noted on the left thigh of a 79-year-old woman. Following the typical pattern, the erythematic area turned to a blue-black color and rapidly formed an eschar deep into the subcutaneous tissue that required debridement. A 70-year-old man was given a warfarin dose of 10 mg daily that was reduced to 2.5 mg daily. It was discontinued when bullous violaceous lesions were discovered on his lower left leg and foot. His prothrombin times never exceeded 20 seconds with a control of 10.6 seconds. A 37-year-old woman was admitted with an erythematous area on her right thigh that turned blue-black and subsequently formed an eschar. Her prothrombin time was 21 seconds with a control of 10.6 seconds. Of the 50 reports of warfarin-induced skin necrosis in the literature (including the four here), 74% of the cases involved women. The mean age of the patients was 54 years, and 60% of the lesions occurred on the thigh, breast, or buttock. Usually the onset of the lesion was noted on days 3--5 of warfarin therapy. Sixty percent of the patients were hypocoagulated. The etiology of warfarin-induced skin necrosis has not been definitively established. In the event of this unusual complication, warfarin therapy should be discontinued, vitamin K should be administered to reverse the effects of warfarin, and heparin should be used to provide anticoagulation.

Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Necrosis; Prothrombin Time; Skin Diseases; Skin Transplantation; Warfarin

Two patients with dermal necrosis due to anticoagulation therapy with warfarin are reported. Both patients demonstrated some disturbance in immunological function. It appears possible that warfarin may act as a hapten in the induction of hypersensitivity to the drug. It is recommended that future cases should be studied to determine whether there is a defect in immunoregulation, and whether circulating immune complexes are responsible for the typical skin lesions.

Topics: Aged; Complement C3; Female; Humans; Immunoglobulin A; Immunoglobulin G; Immunoglobulin M; Immunoglobulins; Lymphocyte Activation; Middle Aged; Necrosis; Phytohemagglutinins; Skin; Skin Diseases; Warfarin

Topics: Adult; Female; Heparin; Humans; Necrosis; Skin Diseases; Warfarin

Topics: Endocarditis, Subacute Bacterial; Female; Gangrene; Humans; Male; Middle Aged; Prothrombin Time; Pulmonary Embolism; Skin Diseases; Warfarin

A 67-year-old woman with a history of thrombophlebitis had been taking warfarin sodium for 1 1/2 years when she developed multiple skin lesions resembling warfarin-induced skin necrosis or purpura fulminans. Despite discontinuing the warfarin and administering prednisone, the lesions increased in size. Disseminated intravascular coagulation (DIC) was found and resolved with heparin sodium therapy, and her skin lesions healed. This patient was believed to have an atypical form of purpura fulminans rather than warfarin-induced skin necrosis because of the duration of warfarin therapy and the dramatic resolution with heparin. A monoclonal (IgG) gammopathy was found, which stabilized as the skin lesions resolved, and fulfilled the criteria for a benign (asymptomatic) monoclonal gammopathy.

Topics: Aged; Diagnosis, Differential; Disseminated Intravascular Coagulation; Female; Humans; Hypergammaglobulinemia; Immunoglobulin G; Necrosis; Purpura; Skin Diseases; Warfarin

Topics: Adipose Tissue; Coumarins; Gangrene; Humans; Leg; Necrosis; Skin; Skin Diseases; Thrombophlebitis; Warfarin

Necrotizing skin lesions developed in a man with chronic ulcerative colitis. No evidence of intrinsic disease of medium or small-sized vessels was found. A circulating cryofibrinogen was thought to be responsible for in situ thrombosis leading to skin infarctions. Sodium warfarin in a daily dose of 2.5 to 5 mg appears to have thwarted progression of developing lesions and the occurrence of new ones.

Topics: Blood Protein Disorders; Chronic Disease; Cold Temperature; Colitis, Ulcerative; Fibrinogen; Humans; Male; Middle Aged; Necrosis; Skin Diseases; Warfarin

Sodium warfarin was administered to a 59-year-old woman with congestive cardiac failure and deep vein thrombosis. After 3 days of therapy the nipple and areola of the left breast became inflamed; the entire breast then became necrotic. Gangrene spread and a simple mastectomy was performed. The patient died from pulmonary embolism 1 day after operation. Histologic examination of the breast revealed thrombi in some of the arteries and veins. The etiology of this condition is obscure, and there is no known way of preventing or effectively treating the condition. Simple mastectomy or more conservative local excision recommended.

Topics: Breast Diseases; Female; Gangrene; Humans; Middle Aged; Skin Diseases; Warfarin

A typical case of skin necrosis following anticoagulant therapy with warfarin is described.

Topics: Female; Heparin; Humans; Necrosis; Pulmonary Embolism; Skin Diseases; Warfarin

Topics: Female; Humans; Middle Aged; Necrosis; Skin Diseases; Warfarin

Topics: Angiography; Blood Protein Disorders; Blood Proteins; Cholesterol; Headache; Humans; Immunoelectrophoresis; Immunoglobulin A; Immunoglobulin G; Immunoglobulin M; Male; Middle Aged; Skin Diseases; Syndrome; Warfarin

Topics: Aortic Valve Stenosis; Gangrene; Heart Valve Prosthesis; Humans; Male; Middle Aged; Skin Diseases; Warfarin

Topics: Adult; Coumarins; Female; Heparin; Humans; Injections, Subcutaneous; Necrosis; Skin Diseases; Warfarin

Topics: Adult; Humans; Male; Middle Aged; Necrosis; Skin Diseases; Thrombophlebitis; Warfarin

Topics: Adolescent; Carcinoma, Hepatocellular; Diagnosis, Differential; Female; Humans; Hypersensitivity; Liver Neoplasms; Necrosis; Skin Diseases; Thigh; Thrombophlebitis; Warfarin

Topics: Aged; Anticoagulants; Female; Heart Failure; Hemorrhage; Humans; Infarction; Necrosis; Skin; Skin Diseases; Warfarin

Topics: Aged; Humans; Male; Myocardial Infarction; Necrosis; Skin Diseases; Warfarin

Topics: Acenocoumarol; Anticoagulants; Coumarins; Dicumarol; Drug Therapy; Ecchymosis; Ethyl Biscoumacetate; Gangrene; Necrosis; Phenindione; Pulmonary Embolism; Purpura; Skin Diseases; Thrombophlebitis; Toxicology; Warfarin