Warfarin-induced skin necrosis: a narrative review of clinical features, risk factors, and treatment strategies.

Warfarin-induced skin necrosis (WSN) is a rare but potentially life-threatening complication of anticoagulation therapy, typically emerging within the first few days of warfarin initiation. It is characterized by painful, hemorrhagic skin lesions that can rapidly progress to full-thickness tissue necrosis. This review, designed as a narrative review, provides a comprehensive and updated overview of WSN, emphasizing its clinical presentation, underlying pathophysiology, risk factors, diagnostic challenges, treatment options, and prevention strategies. A broad literature search was conducted using PubMed, Google Scholar, ScienceDirect, and Scopus, including case reports, retrospective studies, and review articles published between 1943 and 2023. Articles were selected for their relevance to the etiology, clinical features, diagnosis, management, and outcomes of WSN. The review highlights that WSN predominantly affects middle-aged women and is often associated with protein C or S deficiency, initiation of high-dose warfarin without appropriate heparin bridging, and other thrombophilic disorders. Clinical outcomes vary depending on the timing of diagnosis and intervention; early recognition is often associated with complete recovery, whereas delayed treatment may lead to extensive tissue necrosis requiring surgical intervention in up to 40% of cases, with reported mortality rates as high as 15%. Prevention through risk stratification, cautious warfarin dosing, and early recognition remains critical. By consolidating current knowledge, this review aims to support clinicians in identifying patients at risk and implementing timely interventions to improve clinical outcomes.