Necrotizing fasciitis was popularly known as ‘flesh eating disorder’. Looking at the effects necrotizing fasciitis produces to human body, the term flesh eating disorder seems to be correct. This is a mixed bacterial infection involving soft tissue structures below the skin like fascia, septum, tendons and ligaments. Its danger lies in its rapid spread, variable signs of presentation leading to difficulty in early diagnosis and treatment and rapid deterioration of general condition of the patient.
Necrotizing fasciitis is classified into four categories according to the bacteria causing the infection. First type of infection is called synergistic bacterial infection and it usually affects elderly, diabetic and immunocompromised patients. Second and third types of necrotizing fasciitis are caused by different subspecies of bacteria belonging to group clostridia. Clostridial infections are usually caused by penetrating or deep injuries within the muscle and they can affect normal individuals. These infections propagate very fast and if not diagnosed and aggressively treated by radical surgical debridement and aggressive medical management, they can claim life of the patient. Some people have classified fourth type of infections as those arising from fungal infections. Whatever may be the cause of necrotizing fasciitis, the importance of early diagnosis and aggressive surgical debridement and medical management can never be overemphasized.
Symptoms of necrotizing fasciitis are variable. Definite history of injury is not always present. However, patients with or without history of trauma usually present with pain and diffuse swelling of the affected part. Along with pain and swelling, fever, redness of affected skin and in advanced stages of infection, blister formation over affected skin along with bluish or purplish discoloration of skin is observed. Patient might have decreased urine out put with complaint of easy fatigue and feeling weak.
Detailed history and physical examination of the patient are indispensable tools to diagnose necrotizing fasciitis. Definite history of injury particularly penetrating or sharp injury deep within the muscles followed by development of severe pain, swelling and early color changes or blister formation over skin nearby should raise the strong suspicion of necrotizing fasciitis. Blister formation is an alarming sign and typically the blisters are filled with turbid, dirty looking fluid which is usually negative for bacterial culture. Upon rupturing the blister, underlying skin is usually purple or bluish-red and may show thrombosed veins. Patient might have already entered into stage of sepsis on first presentation and if this is the case, patient’s vital data shows tachycardia (increased heart rate), hypotension (decreased blood pressure), tachypnea (increased rate of breathing) with or without fall in oxygen level of blood. Apart from physical examination, laboratory tests also show typical picture of systemic infection. Putting all evidences together, plastic surgeon confirms the diagnosis of necrotizing fasciitis.
Causes of necrotizing fasciitis include any skin injury, skin injury leading to injury of deep muscles, penetrating injury, diabetes, old age, immunocompromised conditions, poor hygienic skin condition, patients with malignancy and idiopathic (cause not known).
Diagnosis of necrotizing fasciitis is based on clinical findings supported by laboratory tests. Detailed history of patient, thorough clinical examination including examining patient’s vital data is of paramount importance. Laboratory tests usually support and help in confirming the diagnosis. Once diagnosis of necrotizing fasciitis is confirmed by a plastic surgeon, it should be considered a surgical emergency and actions need to be taken without wasting time.
Risk factors for development of necrotizing fasciitis are old age, diabetes, obesity, patients on systemic steroid medications, patients on immunosuppressant drugs, patients with malignancy (cancer), tuberculosis, HIV infected patients and many others. Even without any apparent risk factors, necrotizing fasciitis can affect normal individual.
The best way to prevent necrotizing fasciitis is to consult a plastic surgeon immediately after any trauma, however trivial it seems. If there is no history of trauma or any precipitating cause, upon noticing early symptoms of necrotizing fasciitis like pain, swelling or redness of overlying skin, a plastic surgeon must be consulted immediately without wasting time. Deleterious effects of age and other co-morbid conditions are not possible to get rid of.
Treatment of necrotizing fasciitis must involve a plastic surgeon from the beginning. Treatment is a multidisciplinary approach where the roles of a plastic surgeon and an infectious disease specialist are most important. After confirming the diagnosis by established criteria, treatment is started immediately by admitting the patient to intensive care unit with intravenous antibiotics, fluids and supportive care along with continuous monitoring of vital data of the patient. After quick stabilization of the patient and necessary investigations, urgent and radical debridement is carried out by a plastic surgeon which is followed by re look debridement within next 48 to 72 hours. After first one or two debridement and stable vital parameters, patient is shifted to the ward. Prolonged dressings are usually needed to clear the residual discharge and slough. Application of vacuum assisted device to drain the discharge and for better granulation tissue is preferred in many cases.
After healthy granulation tissue is achieved, coverage of the defect by simple plastic surgery option of STG is preferred. However, in certain complex defects, flap coverage is indicated and it enhances the complexity of reconstruction and might prolong the hospital stay. Once complete wound coverage and healing of all the wounds is achieved, patient is discharged from the hospital, but patient needs long term and consistent follow up for physiotherapy and rehabilitation.
Results of treatment of necrotizing fasciitis are generally good, when the patient presents in early stages of the disease and when he has directly presented to a plastic surgeon. However, late presenting patients, patients presenting in advanced stage of disease with septic shock and patients with associated co-morbid conditions do not always perform well. In such situations, even though the treatment is done by a plastic surgeon form the beginning, the mortality rate (death rate) might be significantly high.
Depending upon the severity of the clinical condition, necrotizing fasciitis affects patients’ life. In milder form where cure is achieved with very limited plastic surgical debridement, patient is cured within 3 to 4 weeks. In case of moderate to severe clinical presentation, it might take up to 3 months or more before patient is incorporated in his/her life as before.
Yes, necrotizing fasciitis is curable, provided patient must present to a plastic surgeon during very early stage of disease and patient must co-operate with all decisions made by the treating doctors’ team.
Immediate debridement by a plastic surgeon and treatment by a multidisciplinary team followed by the definite plastic surgical reconstruction is the best remedy for a patient with necrotizing fasciitis.
Because plastic surgeon is well versed about the anatomy of all regions of body, particularly upper and lower limbs. Apart from this, plastic surgeon is expert in dealing with various types of invasive infections of body including skin, subcutaneous tissues and muscles. And by virtue of his/her reconstructive abilities, plastic surgeon can reconstruct the extensive tissue defects resulting after massive debridement. Thus, plastic surgeon is expert in dealing with necrotizing fasciitis at all stages of the disease.
For added protection from this problem, patients with co-morbid conditions (diabetes, old age, tuberculosis, immunosuppressed patients, HIV infected patients) must avoid even the slightest trauma and maintain utmost hygiene.
Essential things to follow to prevent necrotizing fasciitis is to avoid any injury and to maintain the best of hygiene and health, And if any suspicion of this deadly infection is raised, a qualified plastic surgeon must be immediately consulted.
Necrotizing fasciitis is found most frequently in lower limbs and around perineal regions. However, upper limbs are also affected sometimes with necrotizing fasciitis.
We provide effective surgical and non-surgical treatments for all parts of the body. At Cutis Hospital, our cosmetic and plastic surgery team is committed to giving patients safe and high-quality care.
