A 31 year old man presented with extensive deep vein thrombosis in the left lower limb. After initial pre-anticoagulation testing, he was anticoagulated with enoxaparin injection and warfarin tablets with a target INR of 3.0. After achieving the therapeutic range by day 4, enoxaparin was stopped and warfarin, 5 mg, was continued daily without any other medication. Patient presented 2 months later with elevated INR of 5.84, but no bleeding. Tests for antiphospholipid, anti-B2-glycoprotein and anticardiolipin antibodies were negative. Warfarin was stopped and a single dose of Vitamin K1, 10mg, was given. After 48 hours, the patient was started on low dose warfarin, 2mg, without Unfractionated Heparin or Low Molecular Weight Heparin (LMWH). Skin necrosis developed after 3 days as shown in the image below.