Necrotizing Fasciitis of Forearms in Intravenous Heroin User: Case Report of Advanced Wound Management Improving Dressing Tolerance and Expediting Skin Graft
David C. Roberge DO1
Luis Cardenas DO, PhD1,2
1. Department of Surgery, Christiana Care, Newark, DE
2. Acute Surgical Wound Service, Christiana Care, Newark, DE
Intravenous (IV) and “Skin-popping” are methods of injecting illicit drugs that have numerous complications due to subcutaneous deposits or pierced vessels becoming infected and progressing to Necrotizing fasciitis (NF). NF is a medical emergency which endangers the patient’s limb and life secondary to rapid, extensive tissue destruction and despite treatment carries a 33% mortality rate. Poor clinical outcomes among opioid abusers are compounded by mistrust, withdrawal, pain, discrimination, non-compliance and relapse. We present a case of a 29-year-old IV heroin-user who presented on 10/19/2019, started sulfamethoxazole-trimethoprim for cellulitis. 11/30/2019: bilateral forearms had circumferential, malodorous, necrotic eschar; however, she eloped from hospital. 1/24/2020: re-presenting with NF, requiring emergent debridement of right (30x15cm) and left (15x14cm) arms, down to muscle and bone. Tissue cultures demonstrated: Streptococcus pyogenes. Aim: minimize patient/provider concerns postoperatively and maximize healing by integrating Acute Surgical Wound Service (ASWS).
Initial postoperative dressings, daily antibiotic ointment/petroleum gauze, were excruciating despite additional IV hydromorphone. ASWS coordinated dressings to minimize pain and facilitate healing: twice weekly hypochlorous acid*-soaked abdominal pads to cleanse forearms, hydrofiber silver sheets˚ with antimicrobial properties, covered by bordered hydrocellular foam‡ to promote moist healing environment. She tolerated without need for additional analgesics.
The first dressing change, three days later, revealed healthy granulation. A split-thickness skin graft (STSG) was scheduled for the next available date. Postoperatively, negative pressure wound therapy remained over bilateral forearm grafts five days with 100% success on removal.
ASWS incorporated less frequent, less painful combination-dressings facilitating patient/provider trust, rapid granulation, and early STSG. This approach encouraged patient’s hospitalization until adequate healing.
Trademarked Items (if applicable):
*Vashe® Wound Solution, Urgo Medical North America, Fort Worth, Texas, USA
˚Aquacel® Ag Extra™, ConvaTec, Inc., Bridgewater, NJ, USA
‡Allevyn◊ Life, Smith & Nephew, Inc., Fort Worth, Texas, USA