Severe Skin Infections with Hemorrhagic Blisters
Initial Assessment and Management
- The presence of hemorrhagic blisters in severe skin infections should be considered as necrotizing fasciitis until proven otherwise, especially when accompanied by disproportionate pain, rapid progression of lesions, signs of systemic toxicity, or anesthesia of the skin, according to the Infectious Diseases Society of America 1
- Patients with hypotension, elevated creatinine, low bicarbonate, elevated creatine phosphokinase, or C-reactive protein >13 mg/L require immediate hospitalization and urgent surgical evaluation, as recommended by the Infectious Diseases Society of America 1
- The American College of Surgeons recommends that surgical evaluation should be performed within the first 6-12 hours of diagnosis, and debridement should be aggressive, removing all necrotic tissue until viable bleeding tissue is found 1
Laboratory and Microbiological Studies
- The Infectious Diseases Society of America recommends obtaining blood cultures before starting antibiotics, as well as a complete blood count with differential, C-reactive protein, creatinine, bicarbonate, and creatine phosphokinase within the first hours of evaluation 1
- The British Association of Dermatologists recommends performing wound cultures by needle aspiration or punch biopsy, as well as skin biopsy for histopathology and direct immunofluorescence to exclude autoimmune blistering disorders 2, 3
Common Pathogens
- The Infectious Diseases Society of America identifies Streptococcus pyogenes, Staphylococcus aureus (including MRSA), and Vibrio species as common pathogens in necrotizing infections with hemorrhagic blisters 1, 4
Empiric Antibiotic Therapy
- The Infectious Diseases Society of America recommends starting empiric antibiotic therapy immediately after obtaining cultures, covering aerobic and anaerobic organisms, including MRSA, streptococci, and gram-negative bacilli, with a regimen that includes piperacillin-tazobactam, vancomycin, and clindamycin 1, 4
Local Management of Hemorrhagic Blisters
- The British Association of Dermatologists recommends not breaking intact blisters initially, as the blister roof acts as a natural biological dressing that protects against secondary infection, and applying a gentle emollient and a non-adherent dressing 5, 3