title: A case of warfarin skin necrosis despite enoxaparin anticoagulation in a patient with protein S deficiency.
abstract: Warfarin-induced skin necrosis is a rare complication associated with the use of oral anticoagulants. Most patients develop this at the initiation of therapy, often while still receiving intravenous unfractionated heparin (UFH). Recently, low-molecular-weight heparins (LMWHs) have gained wider use, providing an option for outpatient treatment of deep-vein thrombosis. The treatment protocols are similar to UFH, including the early initiation of oral anticoagulation with warfarin. A Medline search failed to reveal any cases of warfarin-induced skin necrosis while using a LMWH. We present a patient with protein S deficiency who developed warfarin skin necrosis despite appropriate anticoagulation with enoxaparin, and review the chemical and clinical difference between UFH and LMWH.
authors.affiliation: Department of Surgery, Cooper Health System University Medical Center, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Camden 08103, USA.
authors.forename: Chau Y
authors.initials: CY
authors.lastname: Tai
authors.forename: Ralph
authors.initials: R
authors.lastname: Ierardi
authors.forename: James B
authors.initials: JB
authors.lastname: Alexander
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects*; D001157:Arterial Occlusive Diseases / Q000601:surgery; D017984:Enoxaparin / Q000627:therapeutic use*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006801:Humans; D008875:Middle Aged; D009336:Necrosis; D011150:Popliteal Artery / Q000601:surgery; D011183:Postoperative Complications / Q000188:drug therapy / Q000209:etiology; D018455:Protein S Deficiency / Q000188:drug therapy*; D012871:Skin Diseases / Q000139:chemically induced*; D013350:Subclavian Vein / Q000473:pathology; D016909:Tibial Arteries / Q000601:surgery; D017211:Treatment Failure; D014656:Vascular Surgical Procedures; D020246:Venous Thrombosis / Q000188:drug therapy / Q000209:etiology; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin; D005343:Fibrinolytic Agents; D006495:Heparin, Low-Molecular-Weight; D014859:Warfarin