Necrotizing and exfoliative diseases of the skin

David A. Sieber, Gerard J. Abood, Richard L. Gamelli

Loyola University Medical Center, Stritch School of Medicine, Chicago, IL, USA

Introduction

Cellulitis

Diseases of the skin are a common problem seen in burn units internationally. These common disorders can be generally classified into two categories: necrotizing soft tissue disorders and exfoliative soft tissue disorders. Oftentimes patients present initially to primary medical centers but ultimately require transfer to tertiary burn centers due to the physiologic derangements associated with the large amount of total body surface area (TBSA) involved as well as for complex dressing care and wound management. As is the case with extensive thermal injuries, patients presenting with exfoliative and necrotizing diseases of the skin present unique challenges to the burn surgeon This chapter will address the relevant pathophysiology, as well as how to promptly diagnose and adequately treat each disease process.

Necrotizing diseases of the skin

The necrotizing skin disorders include a variety of disorders ranging from severe cellulitis to necrotizing fascitis. If these disorders are not treated properly in a prompt manner, severe disfigurement or even death may be the end result. Prompt transfer of these patients to a burn center is necessary to ensure maximal medical care to the patient.

Marc G. Jeschke et al. (eds.), Handbook of Burns

Local cutaneous soft tissue infections commonly occur in what appear to be otherwise healthy patients. These infections may be propagated through minor trauma and are commonly caused by gram-positive organisms such as Staphylococcal and Streptococcal species [1]. These infections may become more severe with major trauma or in patients with compromised immune functions. If not controlled early with adequate antibiotics, these infections may propagate systemically leading to severe sepsis and possibly death [2–4].

Upon presentation, differentiating cellulitis and impetigo from something more serious like necrotizing fascitis is of utmost importance. However, this can often times be a very difficult task [5]. The mainstay of initial treatment for patients presenting with severe cellulitis is the initiation of antibiotic therapy such high dose penicillins [6]. Additional antibiotic coverage is also warranted with Clindamycin, Vancomycin, or another B-lactam antibiotics due to a recent increase in community acquired methicillin resistant Staphylococcus aureus (MRSA) seen in patients presenting with soft tissue infections [7]. Daily wound checks should be instituted as standard of care to ensure improvement in wound appearance and to assess for progression of infection.

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© Springer-Verlag/Wien 2012