|
| Fig. 14.7 Characteristic lesions of warfarin necrosis, demonstrating early necrosis and hemorrhagic bullae surrounded by a ring of erythema. |
The patient is typically a woman who has been given a loading dose of warfarin (Coumadin). Between 3 and 5 days after starting the drug, the patient develops one or more lesions over the thighs, buttocks, or breasts. Initially painful and red, the lesions rapidly become necrotic with hemorrhagic bullae and an erythematous edge (Fig. 14-7). A necrotic eschar rapidly develops. Rapid recognition of the characteristic lesions in the typical situation is the key to reducing tissue destruction. Therapy includes discontinuing warfarin, administering vitamin K to reverse the effect of warfarin, giving heparin as an anticoagulant, and administering monoclonal antibody-purified protein C concentrate. Therapy may also include debridement, grafting, and even amputation. Warfarin necrosis has frequently been associated with low levels of protein C. Most authorities recommend that the warfarin should be discontinued.
