Skin necrosis is a rare complication of treatment with coumarin derivatives. Since it was first identified by Verhagen in 1952, approximately 200 cases of skin necrosis have been reported worldwide, but only 73 have been reported in the English language literature. A telltale clinical scenario of pain and petechiae progressing to sharply demarcated ecchymosis, bullae formation, and gangrenous necrosis manifests most often in the adipose tissues of middle-aged women. Necrosis usually appears within 3 to 6 days of the initiation of warfarin sodium therapy. We report a case of cutaneous necrosis that began 46 days after warfarin sodium therapy was begun.

[Sternberg ML, Pettyjohn FS: Warfarin sodium-induced skin necrosis. Ann Emerg Med July 1995;26:94-97.]