Coumadin-Induced Skin Necrosis

Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN


Wounds. 2002;14(6) 

In This Article

Clinical Presentation

A constellation of typical historical and clinical features is often described in CISN case reports ( Table 1 ). The prototypical patient is an obese, middle-aged, perimenopausal woman being treated for deep vein thrombosis, pulmonary embolism, and cerebrovascular or coronary thrombosis. Classically, the lesions appear in the breast, buttock, abdomen, or thigh where significant underlying subcutaneous fat tissue is present. The condition is most often unilateral, but 30 percent of cases occur bilaterally with multiple lesions. Onset of skin changes may begin from day one to day ten, with a peak incidence on days three to six after initiating Coumadin.[2,6,7] However, case reports indicate CISN occurs much later than the "typical" time of onset.[8] One suggestion for the late-onset phenomenon is lack of drug compliance with patients forgetting, or purposely choosing to omit, the drug on some days.

CISN has affected persons ranging in age from 16 to 93 (median: 54) years.[9] Although the condition also occurs in men, the female:male ratio is described as 9:1. When CISN affects males, the breast is rarely involved, but the penis may be a site of necrosis.[10,11,12]

A classic pattern of skin changes occurs when the condition commences. Patients complain of paresthesias, sensations of pressure, and extreme pain. Areas of erythematous flush may become edematous and have a peau d'orange effect. Within 24 to 48 hours, petechiae develop that progress to hemorrhagic bullae and change quickly to full-blown necrotic eschar. The eschar may eventually slough or require extensive surgical debridement.[11,12]


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