Warfarin induced skin necrosis.

A 54 yr old woman presented to the Medicine Outpatient department, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, in January 2014 with right lower limb pain and swelling. Doppler study confirmed right femoral-popliteal vein deep venous thrombosis (DVT). She was given injection of low-molecular weight heparin (LMWH) 0.6 ml twice daily and warfarin 3 mg once daily. However, due to unavailability she took only four injections of LMWH but continued warfarin. On the 10th day, she came again with complaints of skin discolouration of lower limbs and abdomen (Figure). Diagnosis of warfarin related necrosis was made and she was given intravenouly (iv) vitamin K injection and fresh frozen plasma due to prolonged international normalized ratio (INR, 7.05). Once INR was normalized, LMWH injections were restarted. In view of chances of irregular follow up due to distant home place, she was referred to the local doctor for further care. Thereafter, she successfully received LMWH injections followed by warfarin for the next six months with resolution of skin necrosis. DVT is a common but challenging encounter in clinics. Compliance, dose adjustment, avoidance of vitamin K containing food items are mandatory requirements for the successful treatment. However, in reality many patients default during follow up leading to complications.

Figure

Well defined violaceous patches (thick black arrow) with central bullae formation (thin black arrow). The lesion is surrounded with peripehral rim of erythematous patch. (A) Left thigh, (B) Right thigh, (C) Abdomen, (D) Left foot.