Case Report Dabigatran in the Treatment of Warfarin-Induced Skin Necrosis: A New Hope Christos Bakoyiannis, Georgios Karaolanis, Nikolaos Patelis, Anastasios Maskanakis, Georgios Tsaples, Christos Klonaris, Sotirios Georgopoulos, and Theodoros Liakakos 1st Department of Surgery, Vascular Surgery Unit, Laikon General Hospital, Medical School of Athens, Agiou Toma 17, 11527 Athens, Greece Correspondence should be addressed to Georgios Karaolanis; drgikaraolanis@gmail.com Received 1 January 2016; Accepted 15 March 2016 Academic Editor: Alireza Firooz Copyright © 2016 Christos Bakoyiannis et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Warfarin-induced skin necrosis is an infrequent and well-recognized complication of warfarin treatment. Te incidence was estimated between 0.01% and 0.1% whereas a paradoxal prothrombotic state that arises from warfarin therapy seems to be responsible for this life-threatening disease. To the best of our knowledge we present the frst case of an old woman diagnosed with warfarin-induced skin necrosis, in whom novel oral anticoagulants and extensive surgical debridement were combined safely with excellent results. 1. Introduction Warfarin-induced skin necrosis (WISN) is an infrequent and well-recognized complication of warfarin treatment. In the literature, WISN incidence was estimated between 0.01% and 0.1% [1, 2]. Te accurate pathogenetic mechanism is not clear and the paradoxal prothrombotic state that arises from warfarin therapy seems to be associated with the relative decrease in vitamin K-dependent clotting factors (e.g., protein C) or the hereditary defciencies of protein S, Factor V Leiden, and antithrombin III [3, 4]. Tis imbalance can cause microthrombi which interrupt blood fow to the skin and cause necrosis. We present a case of a 72-year-old woman with skin necrosis afer initiation of warfarin therapy due to atrial fbrillation and who was safely treated with novel oral anticoagulants (NOACs). 2. Case Presentation A 72-year-old woman was admitted to our department due to acute ischemia of the right leg. She was diagnosed with persistent nonvalvular atrial fbrillation 7 days ago, and it was decided that she would beneft from warfarin for stroke prophylaxis. Warfarin was prescribed at 2mg daily as a slow loading dose and on the ffh day the primary care physician increased the dose to 5 mg, due to the low value of the international normalized ratio [INR = 1.5]. Moreover, the patient had a history of hypertension and diabetes mellitus and there was no history of any trauma or local/systemic infection. On physical examination, the right leg of the patient was found to be pale and cold with the sign of developing mottling and cyanosis from knee level down. Te calf muscles were also tender on examination. She had no detectable arterial pulses below her right knee by palpation, which was confrmed by an emergency Doppler examination revealing the complete lack of blood fow in both dorsalis pedis and posterior tibial arteries. Furthermore, a necrotic lesion was revealed measuring 5 cm in diameter on the lateral aspect of lower right leg [Figure 1]. Te diagnosis of acute right leg ischemia due to the acute occlusion of the 3-infrapopliteal arteries was considered. A dose of intravenous (IV) heparin was chosen and lower limb thromboembolectomy (TE) was immediately performed via the right femoral artery. Te patient’s postoperative course was uncomplicated, and the extremity tenderness and mot- tled skin were improved. Moreover, dermatology consults and skin biopsy revealed noninfammatory thrombosis with Hindawi Publishing Corporation Case Reports in Dermatological Medicine Volume 2016, Article ID 3121469, 3 pages http://dx.doi.org/10.1155/2016/3121469