Necrotizing fasciitis and
purpura fulminans are two destructive
infections that involve both skin and soft tissue.
Necrotizing fasciitis is characterized by widespread
necrosis of subcutaneous tissue and the fascia. Historically, group A beta-hemolytic streptococcus has been identified as a major cause of this
infection. However, this monomicrobial
infection is usually associated with some underlying cause, such as
diabetes mellitus. During the last two decades, scientists have found that the pathogenesis of
necrotizing fasciitis is polymicrobial. The diagnosis of
necrotizing fasciitis must be made as soon as possible by examining the skin inflammatory changes. Magnetic resonance imaging is strongly recommended to detect the presence of air within the tissues. Percutaneous aspiration of the
soft tissue infection followed by prompt Gram staining should be conducted with the "finger-test" and rapid-frozen section biopsy examination. Intravenous
antibiotic therapy is one of the cornerstones of managing this life-threatening skin
infection. Surgery is the primary treatment for
necrotizing fasciitis, with early surgical
fasciotomy and
debridement. Following
debridement, skin coverage by either Integra Dermal Regeneration Template or
AlloDerm should be undertaken.
Hyperbaric oxygen therapy complemented by intravenous polyspecific
immunoglobulin are useful adjunctive
therapies.
Purpura fulminans is a rare syndrome of intravascular
thrombosis and hemorrhagic
infarction of the skin; it is rapidly progressive and accompanied by vascular collapse. There are three types of
purpura fulminans: neonatal
purpura fulminans, idiopathic or chronic
purpura fulminans, and acute infectious
purpura fulminans. Clinical presentation of
purpura fulminans involves a premonitory illness followed by the rapid development of a septic syndrome with
fever,
shock, and
disseminated intravascular coagulation. The diagnosis and treatment of these conditions is best accomplished in a regional burn center in which management of
multiple organ failure can be conducted with aggressive
debridement and
fasciotomy of the necrotic skin. The newest revolutionary advancement in the treatment of neonatal
purpura fulminans is the use of activated
protein C.