Dominic, et al. describe a severe case of warfarin-induced skin necrosis with extensive full-thickness tissue loss involving approximately 12 per cent of the body surface area. The early management was conservative, with wound observation only, and no aggressive debridement was attempted. Wound and associated systemic sepsis followed, and the patient was transferred to the burn unit. The wounds were then managed with aggressive therapy including surgical excision, temporary coverage with allograft, and final closure with split-thickness autograft. This case illustrates important principles of appropriate surgical management of extensive skin lesions of this type.(Dominic, Hansbrough et al. 1988)
Necrosis of skin and soft tissue as a complication of oral anticoagulation therapy is a rare condition with approximately 200 cases documented in the world. Coumadin induced skin necrosis is a painful skin lesion, sudden, localized, initially erythematous or hemorrhagic, that becomes bullous and eventually culminates in gangrenous necrosis. Pain and petechiae progressing to sharply demarcated ecchymosis or bullae formation are telltale clinical scenarios. Skin necrosis develops mainly in women around 50 years of age who are usually obese and have been treated for thrombophlebitis or pulmonary embolism. There seems to be a marked predilection for areas with increased subcutaneous fat content, such as breasts, thighs, and buttocks. The injury is so significant that plastic surgery is frequently required to repair the damaged tissue.(Sternberg and Pettyjohn 1995; Miura, Ardenghy et al. 1996)
Development of the complication is not related to the dose of the coumadin or the patient's prothrombin time or underlying disease. Seventy-four to 90 per cent of the reported cases have been in women in the sixth decade of life. The lower half of the body is affected 40 to 80 per cent of the time, and multiple lesions are seen in 40 per cent of the patients. Histologically, the lesions consist of cutaneous infarcts, with fibrin within the walls and lumina of the dermal veins and capillaries. There is a relative lack of inflammation and hemorrhage of the epidermis and endothelium, in contrast to primary vasculitis or lesions caused by excessive anticoagulation with coumadin. Arterial thrombosis is infrequent. The histological features are similar to those of disseminated intravascular coagulation, and that diagnosis must be excluded through clinical and laboratory findings. Histological sections demonstrate cutaneous infarcts with occlusion of deep dermal capillaries and venules by fibrin and platelet thrombi. The necrotic changes extend as far as the deep dermal collagen bands, and there is a relative lack of inflammation.(Bal and Gurba 1991)
Bal and Gurba described the case of a 79 year old male who developed coumadin necrosis about the feet, but fortunately did not involve the skin about the knees.(Bal and Gurba 1991)
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