Necrotizing fasciitis: How reliable are the cutaneous signs?

Abstract

Necrotizing fasciitis (NF) is a surgical emergency. It is often aggressive and characterized by the rapidly progressive inflammatory infection of the fascia that causes extensive necrosis of the subcutaneous tissue and fascia, relatively sparing the muscle and skin tissue. As the disease progresses, thrombosis of the affected cutaneous perforators subsequently devascularizes the overlying skin. The course indeed can be a fulminant one. The diagnosis of NF, especially in the early stages, is extremely challenging, and it can be very close in presentation to other skin and subcutaneous tissue infections. The primary site of the pathology is the deep fascia. Necrosis of the tissues and fascia may manifest as erythema without sharp margins, swelling, warmth, shiny, and exquisitely tender areas. Pain out of proportion to physical examination findings may be observed. The subcutaneous tissue may be firm and indurated such that the underlying muscle groups cannot be distinctly palpated. Eventually, as the overlying skin is stripped of its blood supply, skin necrosis ensues and hemorrhagic bullae form. Bacteremia and sepsis invariably develop when the infection is well established. This paper discusses some of issues related to the cutaneous signs found in NF and also provides a review the current, available literature on the subject matter.

Necrotizing Fasciitis Associated with Hailey-Hailey Disease: A Rare Case

“…erysipelas and cellulitis) in the early stage, but some clinical features (such as warmth, swelling, induration, and poorly defined margins) are helpful in diagnosis. 3 Laboratory investigations are also essential tools for the diagnosis of NF. The Laboratory Risk Indicator for NF (LRINEC) is assessed by six routine laboratory tests and used initially to make an early distinction between NF and other soft tissue infections, and it is also a helpful tool for early diagnosis of NF.…”

Getting it Right the First Time: Frozen Sections for Diagnosing Necrotizing Soft Tissue Infections

“…Histopathologic assessment is beneficial for diagnosing NSTIs, since clinical symptoms are not seldom unreliable [4, 5, 19]. A prior study showed that macroscopic fascial necrosis during surgical exploration has a high positive predictive value, but a low negative predictive value and therefore cannot simply rule out NSTIs [7].…”

Necrotizing fasciitis: an update on epidemiology, diagnostic methods, and treatment

“…Thus, it is imperative for clinicians to swiftly differentiate between these two clinical entities as treatment strategies and prognosis vary significantly. NF patients may also report tenderness, pain, hemodynamic stability, and tissue necrosis [24,25,26]. The pain tends to be out of proportion to the physical findings and patients might encounter sensory loss at the site of involvement.…”

“…Within 1--2 days of the infection, bullae and vesicles may begin to form, accompanied by serosanguinous leakage (intermediate stage of NF), followed by skin necrosis and crepitus (late stage) [29,30 ▪ ]. While bullae formation is observed in 44.5% of cases, skin necrosis and crepitus occur less frequently, at 23.5 and 4.9%, respectively [24]. In type II NSTI, patients’ superficial injuries may go unnoticed until extensive tissue damage has occurred.…”