Conservative management of necrotizing fascitis in children

Necrotizing fascitis (NF) is a severe infection of the subcutaneous tissue and fascia affecting children and adults. Conventional management includes resuscitation, aggressive debridement of necrotic tissue, and sometimes, additional measures such as hyperbaric oxygen and immunoglobulin therapy. This paper reports conservative management of 18 patients with NF with minimal morbidity and mortality.

Patients with NF admitted to our department between January 2000 and February 2004 were included in the study (N = 18). In all cases, the presentation was rapidly progressing cellulitis progressing to cutaneous gangrene between 6 and 18 hours. The patients were managed by aggressive fluid resuscitation, analgesia, broad-spectrum antibiotics, and dressing with liberal quantities of povidone iodine ointment. After separation of the gangrenous skin margins from the surrounding healthy tissue between 24 and 72 hours, dead skin and fascia were removed with forceps on the ward, the wound washed with liberal quantities of water, and the ointment dressing reapplied. This procedure was repeated until all the dead tissue had been removed. Once the wound was granulating, dressings were changed at increasing intervals until healing took place by secondary intention.

The patients were aged between 5 days and 11 years. In all, NF began as a small boil progressing to a rapidly spreading cellulitis. None of the patients was operated during the acute stage of the infection. Blackening of the skin and separation of the edges occurred within 8-72 hours, the dead tissue was allowed to separate from the granulating base and could be removed at the bedside with minimal blood loss. Blood transfusion was required only in 2 patients where hemoglobin was < 9 gm/dL. Of the 18 patients, 6 grew group A streptococci and staphylococci in a polymicrobial wound culture, whereas the other 12 had polymicrobial flora without streptococci. The clinical course and outcomes were similar in both types of wounds. There was 1 death in the study group, and 1 patient required skin grafting. All other survivors had healing by secondary intention without disability. The period for complete epithelization varied between 3 and 8 weeks. Patients were discharged home when 70% of the wound had healed. There was extensive scarring in 3 children with NF involving the back. The other children had minimal or no scarring. None of the patients had any restriction in the movement of limbs or joints. These findings were compared with 16 retrospective patients of NF treated before January 2000 by the conventional approach of aggressive early debridement, the results of the conservative approach were superior with shorter hospital stay, lower number of blood transfusions, earlier appearance of granulation tissue, and shorter duration of complete healing.

We conclude that the conservative management of NF offers advantages in morbidity without compromising the outcome. In our hospital setup, conservative treatment was less expensive and easily carried out. We would therefore advocate conservative management for the treatment of this condition.