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Painful haemorrhagic lesion on calf

Last reviewed: November 2022

Author: Dr Ian Coulson, Consultant Dermatologist and Editor-in-Chief, 2022.

Edited by the DermNet content department

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Background

This 75-year-old woman has developed a painful haemorrhagic lesion in the last 2 days on her lateral calf. She has coronary artery disease and atrial fibrillation. 

She has been on a beta-blocker as well as warfarin for several months. Her INR control has been very erratic.

What has happened to her leg?

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This is coumarin necrosis. It most frequently occurs shortly after the introduction of a coumarin anticoagulant (eg, warfarin).

Why does this occur?

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Natural anticoagulants reduce in concentration before natural pro-coagulants, so that there is the potential for a short period of relative thrombophilia and this can result in dermal vessel thrombosis and subsequent skin necrosis. 

Dermal vessel thrombosis and skin necrosis has been reported in persons with protein S and C deficiency. It is occasionally seen later during anticoagulant treatment particularly if there has been erratic warfarin control.

How should she be managed?

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It can be managed by initiation of heparin, withdrawal of warfarin, and then the use of a new oral anticoagulant which directly inhibits either thrombin or factor Xa. Established necrosis may require devitalised tissue debridement. 

 

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