Necrotizing Dermohypodermitis or Fasciitis?

Sir: I read with great interest the article by Elwood et al. entitled “Periorbital Necrotizing Fasciitis” (Plast. Reconstr. Surg. 120: 107e, 2007). The results shown in the case report are beautiful, but I wanted to point out the need for precision in the denomination of necrotizing soft-tissue infections. These infections constitute a spectrum of disease processes characterized by fulminant, widespread necrosis of soft tissue, systemic toxicity, and high mortality. The terminology used to refer to these diseases is extensive because of the absence of clear definitions and the use of classification systems based on a variety of criteria, including etiologic, microbiologic, anatomical, and clinical aspects. I think we should at least use a classification based on the spread of the infection into deeper regions (e.g., superficial versus deep soft-tissue infections). The involvement of fascia is making a dramatic difference. We have identified two different types of diseases1,2: Necrotizing dermohypodermitis is a superficial infection (necrotizing cellulitis, erysipelas) confined to the cutis and subcutis. The rapid necrotizing process primarily affects the superficial fascia, after which the bacteria proliferate and secondarily invade the subcutaneous tissue. Necrotizing fasciitis is an infection affecting deep fascia and muscle. This infection will spread rapidly along deep fascia and release toxic bacterial products. Skin involvement can develop in time because of thrombosis of the perforating vessels to the skin. As the disease progresses, extensive gangrene of skin, subcutaneous fat, fascia, and sometimes skeletal muscle occurs. As infection progresses and greater quantities of toxins are produced and absorbed, local ischemia likely expands regionally until an entire tissue bed is destroyed. Systemically, microvascular occlusion may also contribute to the shock and organ dysfunction associated with these infections. In the case we are discussing from Elwood et al., several points drove me to the diagnosis of necrotizing dermohypodermitis rather than necrotizing fasciitis, as follows: The delay of evolution: 5 days between the first erythema of the face and the extension of the clinical signals all along the right side of her face and down her right neck. The slowly worsening situation throughout 5 days cannot be related to the diagnosis of necrotizing fasciitis. In case of necrotizing fasciitis of the face, the spread of infection along the deep fascias of the cervix and the face should have produced enough toxic bacterial product to result in profound shock and organ dysfunction in less than 12 hours, even under treatment with antibiotics. Only extensive excision of all involved tissues and fascia could have ended the process. In Figures 1 and 2, we can see the preoperative extension of the disease on all of the lateral side of the face and sufficient excision around the orbital area only. Diagnosis of necrotizing fasciitis must be very specific because, with this disease, only a radical excision of the involved tissues in extreme emergency can save the patient. Alain M. Danino, M.D., Ph.D. Montreal University Hospital Montreal, Quebec, Canada

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