In a warfarin treated patient skin necrosis is found in : a) Protein C deficiency b) Protein S deficiency c) AT III deficiency d) Factor VII deficiency e) Factor X deficiency

**Core Concept**
Warfarin-induced skin necrosis is a rare but serious condition that occurs due to the paradoxical effect of warfarin, leading to a prothrombotic state in certain individuals. This phenomenon is primarily associated with the depletion of protein C, a vitamin K-dependent anticoagulant protein.

**Why the Correct Answer is Right**
Protein C is a key regulator of blood coagulation, and its levels decrease before the levels of other vitamin K-dependent clotting factors. In patients on warfarin, the rapid decline of protein C can lead to a prothrombotic state, particularly in areas with high concentrations of protein C, such as the skin. This results in the formation of venous thrombi, which can cause skin necrosis. The other vitamin K-dependent clotting factors, including factors VII, IX, and X, take longer to decrease, making protein C deficiency the primary cause of warfarin-induced skin necrosis.

**Why Each Wrong Option is Incorrect**
**Option A:** Protein C deficiency is the correct answer, so we'll skip this one.
**Option B:** Protein S is another vitamin K-dependent protein, but its deficiency is not primarily associated with warfarin-induced skin necrosis.
**Option C:** AT III (antithrombin III) is a protease inhibitor that regulates the coagulation cascade, but its deficiency is not directly linked to warfarin-induced skin necrosis.
**Option D:** Factor VII deficiency is a rare bleeding disorder, but it's not the primary cause of warfarin-induced skin necrosis.
**Option E:** Factor X deficiency is another bleeding disorder, but it's not directly associated with warfarin-induced skin necrosis.

**Clinical Pearl / High-Yield Fact**
Warfarin-induced skin necrosis typically occurs within the first few days of warfarin therapy, often in areas with high concentrations of protein C, such as the breasts, thighs, and buttocks. Patients with a history of protein C deficiency or other conditions that affect protein C levels are at higher risk.

**Correct Answer:** a) Protein C deficiency