Necrotizing Fasciitis of Forearms in Intravenous Heroin User: Case Report of Advanced Wound Management Improving Dressing Tolerance and Expediting Skin Graft

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 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<br><br><strong>References&nbsp;(if applicable):