When An Elderly Patient Presents With A Painful Blister And Swelling

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By M. Joel Morse, DPM

   If the area is still painful after 48 hours, apply gentle heat with warm towels, a hot water bottle or a heating pad. Apply heat for 20 minutes at a time to promote absorption and repair. Since heat causes swelling and increases tissue fluid, which may impair function, one may follow hot compresses with cold applications to minimize the secondary effects of heat. Pressure in the form of an elastic adhesive bandage may be helpful to reduce hemorrhage and swelling.

   In a patient on anticoagulants, conservative management always involves temporary discontinuation of the Coumadin and close monitoring of the PT and INR. Prompt surgical decompression and hemostasis is indicated for patients with large progressing hematomas or for patients with nerve compression. 5

   When there is poor resorption of the hematoma, the body will progressively sequester the hematoma. The body slowly eliminates the hematoma and replaces it with a calcium deposit. This is called traumatic myositis ossificans, which most commonly occurs in the skeletal muscle of the arms and legs. 6

   The ulcer of the heel eventually closed and continued to stay closed with the use of the Multipodus splint. The hematoma slowly resolved with the use of warm wet compresses. If I was aware of the diagnosis earlier, I would have tried to evacuate the hematoma or apply the warm compresses earlier during the course of treatment.

In Summary

   Patients taking warfarin are susceptible to numerous drug interactions. The majority of interactions result in an increased risk of hemorrhage, and most, but not all, of these are accompanied by an elevated international normalized ratio.

   One must see these patients every other day when trying to determine the cause of the dermatological issue. One may see skin changes that help to give clues as to the cause of the podiatric problem. It is also valuable to consult with other physicians who are involved with the care of the patient.

Dr. Morse is the President of the American Society of Podiatric Dermatology. He is a Fellow of the American College of Foot and Ankle Surgeons, and the American College of Foot and Ankle Orthopedics and Medicine. Dr. Morse is board certified in foot surgery.

For further reading, see “Expert Insights On Diagnosing Pigmented Skin Lesions” in the April 2005 issue of Podiatry Today.


1. Holbrook AM, et al. Systematic overview of warfarin and its drug and food interactions. Arch Intern Med 2005;165:1095-1106.
2. Hoffman R. Hematology: Basic Principles and Practice, fourth edition. Churchill Livingstone, New York, 2005.
4. Davydov L. Warfarin and amoxicillin/clavulanate drug interaction. Annals Pharmacotherapy 37(3): 367-370, 2003.
5. Sakakibara Y. Lower extremity hematoma as a complication of warfarinization in patients with artificial heart valves. Japanese Heart Journal 40(2):239-245, 1999.
6. Person DA, Pattekar MA. Myosistis Ossificans www.emedicine.com/ PED/topic1538.htm, 2006.
7. Coller BS, Schneiderman PI. Clinical Evaluation of hemorrhagic disorders: the bleeding history and differential diagnosis of purpura. In Hoffman R (ed.): Hematology: Basic Principles and Practice. Chapter 112, fourth edition, Churchill Livingston, 2005.
8. Kennedy M, Krusinski P, Dermatologic manifestations of hematologic disease. http://emedicine.medscape.com/article/1096183-overview, 2006.
9. Wendling P. Differential diagnosis of purpura delineated. Int Med News 38(20):33, 2005.

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