Necrosis of the skin 3-6 days after starting warfarin or 3-6 days after excessive hypocoaguability in a patient on warfarin is characteristic of coumadin necrosis.
The skin is initially painful and edematous, followed by echymosis, hemorrhagic bulla and necrosis. Commonly affected sites include the fatty areas of the thighs, breasts or buttocks but other sites including the penis may be affected. Coumadin-induced necrosis may occur in patients with an inherited or acquired protein C deficiency, in patients with protein S deficiency, or in normal patients. The presumed mechanism is via initial rapid decrease in the protein C anticoagulant activity compared with the slower decline of other vitamin K dependent factors.
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