ArticleClinical and experimental medicine2026
Analysis of the clinical characteristics of warfarin-associated purple toe syndrome.
Article in Clinical and experimental medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Purple toe syndrome (PTS) represents a critical yet underrecognized complication of warfarin therapy. To characterize this condition, we conducted a retrospective analysis of all reported warfarin-associated PTS cases through April 30, 2025, without language restrictions. A total of 26 patients (17 male, 9 female) with a median age of 68 years were identified. Of these, 76.9% had pre-existing atherosclerotic disease and 66.7% showed elevated serum creatinine. Symptom onset occurred within three months of warfarin initiation in 53.9% of cases, with 84.0% exhibiting classic bilateral lower extremity involvement characterized by painful violaceous discoloration. Management strategies included warfarin discontinuation (88.5%), dose reduction (7.7%), renal replacement therapy (15.4%), LDL apheresis (11.5%), surgical or endovascular interventions (7.7%), and transition to alternative anticoagulant therapy. Notably, no cross-reactivity between anticoagulant classes was observed, and warfarin rechallenge was not categorically contraindicated in all cases. Outcomes were favorable in 69.2% of patients (symptom resolution), though 3.8% required amputation and 19.2% died within one year, suggesting this complication carries substantial morbidity despite therapeutic intervention. These finding suggest that warfarin-associated PTS warrants clinical awareness, particularly in elderly patients with pre-existing atherosclerotic disease and renal impairment. Early detection, warfarin cessation, and initiation of alternative anticoagulation appear important to help prevent irreversible outcomes.
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