What is the treatment for skin necrosis?

Treatment of Skin Necrosis

The treatment of skin necrosis requires prompt surgical debridement of necrotic tissue as the primary intervention, followed by appropriate wound care and management of the underlying cause. 1 This approach is essential to prevent further tissue damage and promote healing.

Diagnosis and Assessment

Before initiating treatment, proper assessment is critical:

• Evaluate the extent and depth of necrosis
• Identify the underlying cause (common causes include):
  • Necrotizing soft tissue infections
  • Extravasation of medications/contrast agents
  • Anticoagulant-induced necrosis (warfarin, heparin)
  • Radiation-induced injury
  • Vascular occlusion

Treatment Algorithm

1. Immediate Management

• Surgical Intervention:

  • Prompt surgical debridement of all necrotic tissue 1
  • Wide, three-dimensional excision of involved tissue 1
  • Temporary coverage with biologic dressing 1
  • Delayed application of split-thickness skin graft (usually 2-3 days after debridement) 1

• Antimicrobial Therapy (if infection present):

  • Broad-spectrum antibiotics targeting both aerobic and anaerobic organisms 1
  • Adjust based on culture results

2. Cause-Specific Management

For Extravasation Necrosis:

• For anthracycline extravasation:
  • Intravenous dexrazoxane (1000, and 500 mg/m² over 3 days) starting within 6 hours 1
  • Avoid topical DMSO and remove cooling 15 minutes before dexrazoxane administration 1

For Vinca Alkaloid Extravasation:

• Local infiltration with hyaluronidase (150 U/ml solution) 1
• Typically 1 ml of hyaluronidase for 1 ml of extravasated drug 1

For Warfarin-Induced Skin Necrosis:

• Discontinue warfarin immediately 1
• Administer therapeutic doses of parenteral anticoagulants 1
• For patients requiring long-term anticoagulation:
  • Restart warfarin at low dose (e.g., 2 mg) under coverage of therapeutic parenteral anticoagulation
  • Gradually increase warfarin dose over 1+ weeks 1

For Radiation-Induced Necrosis:

• Mechanical protection of the affected skin is crucial 1
• Avoid pressure or friction to the affected area 1
• Supportive dermatological care 1

3. Wound Care

• For Non-Infected Wounds:

  • Moist wound healing principles
  • Appropriate dressings based on wound characteristics
  • Regular wound assessment and dressing changes

• For Infected Wounds:

  • Continued debridement as needed (typically every 24-36 hours until no further necrosis) 1
  • Aggressive fluid management to replace fluid losses 1

4. Multidisciplinary Approach

For complex cases, involve a multidisciplinary team 1:

• Surgeons (plastic, general)
• Infectious disease specialists
• Intensivists (if systemic involvement)
• Wound care specialists
• Rehabilitation specialists

Special Considerations

Necrotizing Fasciitis

• Requires immediate surgical exploration and debridement 1
• Patients should return to the operating room 24-36 hours after initial debridement and daily thereafter until no further debridement is needed 1
• Aggressive fluid resuscitation is essential 1

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

• Requires specialized care in burn centers or PICUs with experience in treating extensive skin loss 1
• Barrier nursing in a controlled environment (temperature 25-28°C) 1
• Careful fluid balance monitoring and replacement 1

Prevention

• For patients at risk of radiation-induced skin injury:

  • Counsel patients receiving high radiation doses about possibility of skin injury 1
  • Instruct on recognizing early signs 1

• For patients on anticoagulants:

  • Careful monitoring during initiation of therapy, especially in patients with protein C deficiency 1
  • Gradual dose escalation when restarting warfarin in patients with history of skin necrosis 1

Follow-up Care

• Regular wound assessment
• Rehabilitation to restore function
• Long-term monitoring for complications
• Psychological support for patients with extensive scarring or disfigurement

The key to successful management of skin necrosis is early recognition, prompt surgical intervention, and appropriate treatment of the underlying cause, with ongoing wound care tailored to the specific needs of the patient.