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Dermatologic Manifestations of Necrotizing Fasciitis

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jun 07, 2016
 

Overview

Necrotizing fasciitis is a severe, insidiously advancing, soft-tissue infection characterized by widespread fascial necrosis (see the image below). A number of bacteria in isolation or as a polymicrobial infection can cause this condition.[1] The organisms most closely linked to necrotizing fasciitis are group A beta-hemolytic streptococci, although the disease may also be caused by other bacteria or different streptococcal serotypes. In Texas from 2001-2002 and from 2009-2010, a rising incidence of necrotizing fasciitis of 5.9 versus 7.6 cases per 100,000 population has been documented, although hospital mortality (9.3%) was unchanged.[2]

Left upper extremity shows necrotizing fascitis in Left upper extremity shows necrotizing fascitis in an individual who used illicit drugs. Cultures grew Streptococcus milleri and anaerobes (Prevotella species). Patient would grease, or lick, the needle before injection.

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Types of Necrotizing Fasciitis

Familiarity with necrotizing fasciitis may facilitate earlier diagnosis and initiation of appropriate therapy. This infection may occur as a complication of a variety of surgical procedures or medical conditions, including cardiac catheterization,[3] vein sclerotherapy,[4] and diagnostic laparoscopy,[5] among others.[6, 7, 8, 9, 10, 11] Necrotizing fasciitis can appear in a variety of sites after a number of encounters, including a stonefish sting,[12] following a shoulder sprain in a previously healthy person,[13] on a swollen breast,[14] and as a complication of acne appearing initially as lip cellulitis.[15]

Type I, or polymicrobial necrotizing fasciitis, usually occurs after trauma or surgery. This form may initially be mistaken for a simple wound cellulitis. However, severe pain and systemic toxicity reflect widespread tissue necrosis underlying apparently viable skin. This disease process may also be observed in association with urogenital or anogenital infections below).[16]

Type II, or group A streptococcal necrotizing fasciitis, is the so-called flesh-eating bacterial infection.[8]

Type III necrotizing fasciitis, or clostridial myonecrosis, is gas gangrene. This skeletal muscle infection may be associated with recent surgery or trauma.

Type IV can be designated as fungal necrotizing fasciitis. Since necrotizing fasciitis is rarely caused by or complicated by a fungus, the authors of this Medscape Reference article (Schwarz and Kapila) have designed it as type IV. In any case, early fungal smear and culture should be considered.[17] Candidal species may be etiologic,[18] possibly combined with a bacterial etiology such as Streptococcus pyogenes.[19]

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Clinical Evaluation

In a study of 20 patients with necrotizing fasciitis with a median age was 52.5 years, the overall mortality rate was only 8.3%, attributed to early diagnosis and treatment.[20] Half had a comorbidity such as diabetes mellitus or congestive heart failure.

Patients with necrotizing fasciitis tend to present with erythema and supralesional vesiculation or bullae formation 2-3 days following constitutional symptoms of fever and chills. Serosanguineous fluid may drain from the affected area.

From a rapidly advancing erythema, painless ulcers may appear as the infection spreads along the fascial planes. A black necrotic eschar may be evident at the borders of the affected areas, and metastatic cutaneous plaques may occur.

Purpura with or without bullae formation, occasionally with a lack of cutaneous erythema and heat, may be found, but this does not preclude the diagnosis of necrotizing fasciitis.[21] Gas may be evident; this process may also be observed in the perineum in association with urogenital or anogenital infections (eg, Fournier gangrene).

Necrotizing fasciitis may develop after skin biopsy; at needle puncture sites in those use illicit drugs; and after episodes of frostbite, chronic venous leg ulcers, open bone fractures, insect bites, surgical wounds, and skin abscesses. It has even been described affecting the perineum and genital region due to excessive masturbation in an otherwise healthy man with severe scrotal pain and swelling and frequent masturbation who had used soap as a lubricant, resulting in recurrent penile erythema and minor skin abrasions.[22]

See the images below.

Massive perineal ulceration with foul-smelling dis Massive perineal ulceration with foul-smelling discharge in a 60-year-old woman who had undergone postvaginal hysterectomy and repair of a rectal prolapse. Cultures revealed Escherichia coli and Bacteroides fragilis. The diagnosis was peroneal gangrene.
Necrotizing fascitis at a possible site of insulin Necrotizing fascitis at a possible site of insulin injection in the left upper part of the thigh in a 50-year-old obese woman with diabetes.

However, in many cases, no association with such factors can be made. Necrotizing fasciitis may also occur in the setting of diabetes mellitus, surgery, trauma, or infectious processes.

Necrotizing fasciitis causes thrombosis of fascial blood vessels, producing a true surgical emergency. Although thickening of the deep fasciae as a result of fluid accumulation and reactive hyperemia may be visualized using computed tomography and magnetic resonance imaging, these findings are not specific for necrotizing fasciitis.[23] Thus, although imaging studies can confirm the diagnosis and evaluate spread, they should not delay emergency surgical treatment.

In type II necrotizing fasciitis, the widespread tissue necrosis underlying the apparently viable skin can be demonstrated by passing a probe through the tissue. The condition may appear similar to a simple wound cellulitis; however, the severe pain and systemic toxicity reflect the widespread tissue necrosis underlying the apparently viable skin. When surgically confirmed necrotizing fasciitis cases were compared with 12 patients with superficial soft-tissue infection, the patients with necrotizing fasciitis were more likely to have skin areas of ischemia or necrosis, fluid-filled vesicles, and severe sepsis or septic shock.[24]

Gas usually is not evident in affected tissues in type II necrotizing fasciitis. Although the following features can occur with cellulitis, they may instead suggest necrotizing fasciitis:

  • Rapid progression
  • Poor therapeutic response
  • Blistering necrosis
  • Cyanosis
  • Extreme local tenderness
  • High temperature
  • Tachycardia
  • Hypotension
  • Altered level of consciousness

Pediatric cases

In a pediatric necrotizing fasciitis series, clinical features began 1 week after the initiating event, beginning with edema and induration, which was followed in 24-48 hours by erythema or a violaceous discoloration.[25] Pain and, occasionally, crepitation, was also noted early. Crepitation indicates the presence of gas produced by aerobic and anaerobic bacteria and is highly suggestive of the diagnosis of necrotizing fasciitis; this finding is often present in patients with diabetes and in those with nonclostridial anaerobic infections. In a series of 39 pediatric cases, the most common initiating factor in 13 of them was varicella.[26]

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Differential Diagnosis

Limb- and life-threatening hand and foot infections, including necrotizing fasciitis, in diabetic patients account for substantial morbidity and mortality.[27] Of 56 patients in one series, 17 (30.36%) had necrotizing cellulitis, 12 (21.43%) had wet gangrene, 9 (16.07%) had acute extensive osteomyelitis, 5 (8.93%) had dry gangrene, 5 (8.93%) had gas gangrene, 4 (7.14%) had necrotizing fasciitis, and 4 (7.14%) had diffuse hand infections.

Other conditions that should be considered when evaluating a patient with suspected necrotizing fasciitis include the following:

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Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Rajendra Kapila, MD, MBBS Professor, Department of Medicine, Rutgers New Jersey Medical School

Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, Infectious Diseases Society of New Jersey

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Van Perry, MD Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio

Van Perry, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Janet Fairley, MD Professor and Head, Department of Dermatology, University of Iowa, Roy J and Lucille A Carver College of Medicine

Janet Fairley, MD is a member of the following medical societies: American Academy of Dermatology, American Federation for Medical Research, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

References
  1. Kihiczak GG, Schwartz RA, Kapila R. Necrotizing fasciitis: a deadly infection. J Eur Acad Dermatol Venereol. 2006 Apr. 20(4):365-9. [Medline].

  2. Oud L, Watkins P. Contemporary trends of the epidemiology, clinical characteristics, and resource utilization of necrotizing fasciitis in Texas: a population-based cohort study. Crit Care Res Pract. 2015. 2015:618067. [Medline]. [Full Text].

  3. Federman DG, Kravetz JD, Kirsner RS. Necrotizing fasciitis and cardiac catheterization. Cutis. 2004 Jan. 73(1):49-52. [Medline].

  4. Chan HT, Low J, Wilson L, et al. Case cluster of necrotizing fasciitis and cellulitis associated with vein sclerotherapy. Emerg Infect Dis. 2008 Jan. 14(1):180-1. [Medline].

  5. Bharathan R, Hanson M. Diagnostic laparoscopy complicated by group A streptococcal necrotizing fasciitis. J Minim Invasive Gynecol. 2010 Jan-Feb. 17(1):121-3. [Medline].

  6. Akcay EK, Cagil N, Yulek F, et al. Necrotizing fasciitis of eyelid secondary to parotitis. Eur J Ophthalmol. 2008 Jan-Feb. 18(1):128-30. [Medline].

  7. Anwar UM, Ahmad M, Sharpe DT. Necrotizing fasciitis after liposculpture. Aesthetic Plast Surg. 2004 Nov-Dec. 28(6):426-7. [Medline].

  8. Bisno AL, Cockerill FR 3rd, Bermudez CT. The initial outpatient-physician encounter in group A streptococcal necrotizing fasciitis. Clin Infect Dis. 2000 Aug. 31(2):607-8. [Medline].

  9. Gibbon KL, Bewley AP. Acquired streptococcal necrotizing fasciitis following excision of malignant melanoma. Br J Dermatol. 1999 Oct. 141(4):717-9. [Medline].

  10. Sewell GS, Hsu VP, Jones SR. Zoster gangrenosum: necrotizing fasciitis as a complication of herpes zoster. Am J Med. 2000 Apr 15. 108(6):520-1. [Medline].

  11. Tung-Yiu W, Jehn-Shyun H, Ching-Hung C, et al. Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases. J Oral Maxillofac Surg. 2000 Dec. 58(12):1347-52; discussion 1353. [Medline].

  12. Tang WM, Fung KK, Cheng VC, et al. Rapidly progressive necrotising fasciitis following a stonefish sting: a report of two cases. J Orthop Surg (Hong Kong). 2006 Apr. 14(1):67-70. [Medline].

  13. Kim HJ, Kim DH, Ko DH. Coagulase-positive staphylococcal necrotizing fasciitis subsequent to shoulder sprain in a healthy woman. Clin Orthop Surg. 2010 Dec. 2(4):256-9. [Medline]. [Full Text].

  14. Marongiu F, Buggi F, Mingozzi M, Curcio A, Folli S. A rare case of primary necrotising fasciitis of the breast: combined use of hyperbaric oxygen and negative pressure wound therapy to conserve the breast. Review of literature. Int Wound J. 2016 May 5. [Medline].

  15. Eltayeb AS, Ahmad AG, Elbeshir EI. A case of labio-facial necrotizing fasciitis complicating acne. BMC Res Notes. 2016 Apr 23. 9 (1):232. [Medline].

  16. Dahm P, Roland FH, Vaslef SN, et al. Outcome analysis in patients with primary necrotizing fasciitis of the male genitalia. Urology. 2000 Jul. 56(1):31-5; discussion 35-6. [Medline].

  17. Prasanna Kumar S, Ravikumar A, Somu L. Fungal necrotizing fasciitis of the head and neck in 3 patients with uncontrolled diabetes. Ear Nose Throat J. 2014 Mar. 93(3):E18-21. [Medline].

  18. Yu SN, Kim TH, Lee EJ, Choo EJ, Jeon MH, Jung YG, et al. Necrotizing fasciitis in three university hospitals in Korea: a change in causative microorganisms and risk factors of mortality during the last decade. Infect Chemother. 2013 Dec. 45(4):387-93. [Medline]. [Full Text].

  19. Zhang M, Chelnis J, Mawn LA. Periorbital Necrotizing Fasciitis Secondary to Candida parapsilosis and Streptococcus pyogenes. Ophthal Plast Reconstr Surg. 2015 Apr 20. [Medline].

  20. Bucca K, Spencer R, Orford N, Cattigan C, Athan E, McDonald A. Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study. ANZ J Surg. 2012 Sep 19. [Medline].

  21. Iwata Y, Sato S, Murase Y, et al. Five cases of necrotizing fasciitis: lack of skin inflammatory signs as a clinical clue for the fulminant type. J Dermatol. 2008 Nov. 35(11):719-25. [Medline].

  22. Heiner JD, Eng KD, Bialowas TA, Devita D. Fournier's Gangrene due to Masturbation in an Otherwise Healthy Male. Case Rep Emerg Med. 2012. 2012:154025. [Medline]. [Full Text].

  23. Malghem J, Lecouvet FE, Omoumi P, Maldague BE, Vande Berg BC. Necrotizing fasciitis: Contribution and limitations of diagnostic imaging. Joint Bone Spine. 2012 Oct 5. [Medline].

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  25. Fustes-Morales A, Gutierrez-Castrellon P, Duran-Mckinster C, et al. Necrotizing fasciitis: report of 39 pediatric cases. Arch Dermatol. 2002 Jul. 138(7):893-9. [Medline].

  26. Ford LM, Waksman J. Necrotizing fasciitis during primary varicella. Pediatrics. 2000 Jun. 105(6):1372-3; author reply 1373-5. [Medline].

  27. Bahebeck J, Sobgui E, Fonfoe L, et al. Limb-threatening and Life-threatening Diabetic Extremities: Clinical Patterns and Outcomes in 56 Patients. J Foot Ankle Surg. 2010 January - February. 49(1):43-46. [Medline].

 
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Left upper extremity shows necrotizing fascitis in an individual who used illicit drugs. Cultures grew Streptococcus milleri and anaerobes (Prevotella species). Patient would grease, or lick, the needle before injection.
Left lower extremity in a 56-year-old patient with alcoholism who was found comatose after binge drinking. Surgical drainage was performed to treat the pyomyositis-related, large, non–foul-smelling (sweetish) bullae. Gram staining showed the presence of gram-positive rods. Cultures revealed Clostridium perfringens. The diagnosis was clostridial myonecrosis.
Massive perineal ulceration with foul-smelling discharge in a 60-year-old woman who had undergone postvaginal hysterectomy and repair of a rectal prolapse. Cultures revealed Escherichia coli and Bacteroides fragilis. The diagnosis was peroneal gangrene.
Necrotizing fascitis at a possible site of insulin injection in the left upper part of the thigh in a 50-year-old obese woman with diabetes.
Necrotizing fascitis of entire thoracolumbar posterior area in 20-year-old patient with chronic myelogenous leukemia and neutropenia (white blood cell [WBC] count, 680/µL). Cultures revealed gram-negative Pseudomonas species and Bacteroides fragilis.
 
 
 
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