What is the workup and treatment for skin necrosis?

Workup and Treatment for Skin Necrosis

The management of skin necrosis requires immediate multidisciplinary team involvement, with urgent surgical debridement as the primary therapeutic modality for necrotizing soft tissue infections, followed by appropriate antimicrobial therapy and supportive care. 1

Diagnostic Workup

Clinical Assessment

• Look for key warning signs of necrotizing infections: pain disproportionate to clinical findings, failure to respond to initial antibiotics, wooden feel of subcutaneous tissue, systemic toxicity with altered mental status, edema extending beyond erythema, crepitus, bullous lesions, and skin necrosis 1
• Assess vital signs including temperature, blood pressure, respiratory rate, and mental status to evaluate for sepsis using qSOFA criteria (systolic BP ≤100 mmHg, respiratory rate ≥22, altered mentation) 1
• Determine the extent of skin involvement using body surface area calculations, particularly important when >10% is affected 1

Laboratory Investigations

• Obtain complete blood count, electrolytes, renal and liver function tests, glucose, magnesium, phosphate, and bicarbonate levels 1
• Take bacterial swabs from three areas of lesional skin, particularly sloughy or crusted areas, for culture and sensitivity 1
• Consider mycoplasma serology if Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is suspected 1

Imaging and Additional Testing

• CT or MRI may show edema extending along fascial planes, though sensitivity and specificity are not well defined 1
• Skin biopsy from lesional skin, just adjacent to a blister, for histopathology to confirm diagnosis 1
• For suspected necrotizing fasciitis, exploratory incision may provide both diagnosis and treatment 1

Treatment Approach

Initial Management

• Immediately withdraw any causative agent (e.g., medication) if drug-induced necrosis is suspected 1
• Establish peripheral venous access through non-lesional skin whenever possible 1
• Monitor fluid balance carefully and catheterize if clinically indicated 1
• Provide adequate intravenous fluid replacement guided by urine output and other end-point measurements 1

Surgical Management

• Surgical intervention is the primary therapeutic modality for necrotizing fasciitis 1
• Debridement of all necrotic tissue should be performed, with patients returning to the operating room 24-36 hours after initial debridement and daily thereafter until no further debridement is needed 1
• For SJS/TEN, consider a conservative approach initially, but transfer to a burn center if there is clinical deterioration, extension of epidermal detachment, subepidermal pus, local sepsis, or delayed healing 1
• In cases of drug-induced skin necrosis (e.g., heparin, warfarin), discontinue the offending agent immediately 2, 3

Antimicrobial Therapy

• For necrotizing soft tissue infections, start broad-spectrum antibiotics covering both gram-positive (including MRSA) and gram-negative pathogens 1, 4
• Recommended regimens include vancomycin, linezolid, or daptomycin combined with either piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole 1
• For group A streptococcal necrotizing fasciitis, use both clindamycin and penicillin to suppress toxin production 1
• Continue antimicrobial therapy until further debridement is no longer necessary, the patient has improved clinically, and fever has been absent for 48-72 hours 1

Wound Care

• For SJS/TEN, apply a greasy emollient over the whole epidermis, including denuded areas 1
• Apply nonadherent dressings to denuded dermis and use secondary foam or burn dressings to collect exudate 1
• Regularly cleanse wounds using warmed sterile water, saline, or an antimicrobial such as chlorhexidine 1
• For necrotizing fasciitis, aggressive fluid administration is necessary due to copious discharge of tissue fluid 1

Specific Interventions for Chemical/Drug-Induced Necrosis

• For anthracycline extravasation, administer intravenous dexrazoxane (1000, and 500 mg/m² over 3 days) starting within 6 hours of extravasation 1
• For vinca alkaloid extravasation, consider local infiltration with hyaluronidase (1 ml of 150 U/ml solution for each ml of extravasated drug) 1
• For warfarin-induced skin necrosis, prompt discontinuation of warfarin and correction of coagulation abnormalities may prevent permanent tissue damage 3

Supportive Care

• Provide adequate pain control using a patient-appropriate validated pain tool for assessment 1
• Ensure adequate nutrition, delivering 20-25 kcal/kg daily during the early catabolic phase and 25-30 kcal/kg daily during recovery 1
• Maintain ambient temperature between 25°C and 28°C for patients with extensive skin loss 1
• Consider barrier nursing in a side room to reduce nosocomial infections 1

Monitoring and Follow-up

• Document each incident of skin necrosis thoroughly, including patient information, date and time of onset, causative factors, signs and symptoms, and management steps 1
• Monitor for signs of systemic infection such as confusion, hypotension, reduced urine output, and reduced oxygen saturation 1
• Consider photographic documentation for follow-up procedures and decision-making 1
• Evaluate for complications including secondary bacterial infections 5

Special Considerations

• For children with SJS/TEN, admission to a pediatric intensive care unit or burn center with experience in treating extensive skin loss is recommended 1
• For necrotizing pneumonia, surgical intervention should generally be avoided as most cases resolve with antibiotics alone 5
• For dermal filler-induced necrosis, high-dose corticosteroid therapy may help in the healing process 6