Man With Painful Skin Lesion
Article Outline
[Ann Emerg Med. 2010;55:302.]
A 53-year-old man presented with a painful skin lesion on his left lower leg, without trauma. The lesion was initially pruritic and had appeared spontaneously 2 weeks earlier. The patient had been evaluated 1 week earlier and was prescribed clindamycin for presumed cellulitis. Despite this, the lesion continued to grow. The patient had a history of peripheral vascular disease and had resumed receiving warfarin sodium for this 1 week before appearance of the lesion. On physical examination, the patient was afebrile, with a 5-cm-×-7-cm nonraised area of ecchymosis with an erythematous border on the anterior left lower leg (Figure).
Figure.
Ecchymotic leg lesion. Used with permission of Derek M. Sorensen, MD, University of Illinois at Chicago Emergency Medicine Residency Program, University of Illinois College of Medicine, Chicago, IL.
Diagnosis
Warfarin sodium skin necrosis
Necrotic skin lesions develop in 0.01% to 0.1% of patients receiving warfarin sodium, with the majority of cases in women.1, 2 The lesions most commonly occur on the breast, buttock, or thigh.3, 4 The majority of cases of warfarin sodium skin necrosis occur within 3 to 6 days of starting therapy, though it may occur after months or even years.5
The lesions are typically painful, localized, abrupt in onset, and the result of thrombosis of the underlying microvasculature. The first sign is an evanescent flush, followed by petechial hemorrhages that coalesce into a well-demarcated ecchymosis. Within hours, hemorrhagic bullae may form. Warfarin sodium skin necrosis may be confused with necrotizing fasciitis or purpura fulminans.
Treatment of warfarin sodium skin necrosis is supportive, with wound care, debridement, and occasionally skin grafting.5 Warfarin sodium is typically withheld, with the use of heparin as bridging therapy for those patients who require long-term anticoagulation.
References
- Warfarin induced skin necrosis. Br J Surg. 2000;87:266–272
- . Warfarin-induced skin necrosis. Am J Emerg Med. 1998;16:541–543
- Petechiae, ecchymosis, and necrosis of skin induced by coumarin congeners: rare, occasionally lethal complication of anticoagulant therapy. JAMA. 1965;192:107–112
- . Coumarin necrosis: a review of the literature. Surgery. 1988;103:271–277
- . Atypical warfarin-induced skin necrosis. Pharmacotherapy. 2006;26:1175–1179
For the diagnosis and teaching points, see page 305.
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PII: S0196-0644(09)00647-7
doi:10.1016/j.annemergmed.2009.06.016
© 2009 Published by Elsevier Inc.
