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Excessive Internal Pressure
(Dissecting Hematoma, Abdominal
Hyperpressure, Abscesses, etc.)
Leading toSkin Necrosis
LucTéot
15
15.1 Introduction
Hyperpressure coming from inside is encountered in different clinical situations potentially
leading to skin necrosis. Abdominal hyperpressure, dissecting hematoma, excessive edema, and
infected collection are the most encountered
causes of a progressive skin devascularization,
leading to an occlusion of the dermal arteriolar
system, causing necrosis of the skin.
15.2 Gastroschisis
Early management of large open abdomen occurring in gastroschisis during the neonatal period is
mostly realized using mesh prosthesis. This very
specialized surgical procedure should take care
about the potential pulmonary hyperpressure
together with an abdominal hyperpressure if an
excessive tension is exerted over the abdominal
fascial edges. The use of foreign implant material
(Teon, polytetrauoroethylene patch) was
reported to enhance the risk of mechanical hyperpressure and infection. This technique also
imposes some degree of skin undermining, with
potential complications, from a transient ischemia
L. Téot (*)
Department of Plastic Surgery, Burns and Wound
Healing, Montpellier University Hospital, Hôpital La
Colombière, CICAT Occitanie,
Montpellier Cedex 5, France
e-mail: l-teot@chu-montpellier.fr
to a complete necrosis, leading in some cases to an
infected prosthesis varying from 3% to 10% [1, 2].
Surgical procedures like myocutaneous aps are
needed in case of large skin necrosis [3].
15.3 Dissecting Hematoma
Hyperpressure induced by a progressing collection between the muscular fascia and the skin
may be devastating for the skin. Blood impregnation of the fatty subcutaneous tissues transforms
the mechanical properties of the skin, limiting the
skin elasticity and creating a bumpy surface over
a nonmobile area.
Elderly women are more affected than men,
and the leg is the affected part; a predisposing
factor is the dermatoporotic skin encountered in
the elderly. Systemic corticosteroids and anticoagulation are also frequently observed.
Skin necrosis appears after a period of edema,
confounding the clinical aspect with erysipelas,
and an antibiotherapy was often started.
Dissecting hematomas are rarely seen by an
expert before 2–3weeks. The diagnosis is conrmed by echography or RMI. Deep incision,
clot evacuation, and debridement are the key elements to prevent local infection and allow wound
healing [4].
© The Author(s) 2024
L. Téot et al. (eds.), Skin Necrosis, https://doi.org/10.1007/978-3-031-60954-1_15
117
118
15.4 Foreign Bodies
andParaosteoarthropathy
Pressure ulcers occurring in neurologically decient patients presenting paraosteoarthropathy
can be found in the literature [5]. The mechanisms generating a PU are comparable to pressure ulcers, with an extended risk linked to the
heterotopic bone formation located supercially
in the deep part of the skin. These heterotopic
formations are usually located under the subcutaneous tissues, forming a nonelastic sheet with
anarchic surface. In paraplegic patients, the position inside a rolling chair may induce an excessive pressure over the heterotopic subcutaneous
bone formation in regard to the hip. Large hematomas may be observed, with the risk of heterotopic bone infection leading to the difculty to
heal and adding a risk of hip septic arthritis.
Large debridement including all foreign bodies
followed by NPWT Instill preparing ap surgery
may be considered as the standard of care.
Heterotopic ossications may be observed in
leg ulcers [6] and in the extremities of amputated
limbs, both in BK and AK amputations.
Calciphylaxis is observed in patients presenting a chronic renal insufciency under frequent
hemodialysis. Calcication of subdermal fat may
L. Té ot
Fig. 15.1 Large abdominal calciphylaxis in a patient presenting a chronic renal insufciency under hemodialysis
induce rigid calcied blocks capable of skin perforation leading to severe infection (Fig.15.1).
15.5 Diabetic Foot Abscesses
Wagner stage 4 cases involving large cavities in a
diabetic foot should be considered as a surgical
emergency and admitted rapidly in a specialized
center [7, 8]. However, when this organization of
care cannot be realized, some emergency protocols may save tissue.
15 Excessive Internal Pressure (Dissecting Hematoma, Abdominal Hyperpressure, Abscesses, etc.…
119
1: abcess hyperpressure
inducing tissue damage
3: wire drainage
Fig. 15.2 Schematic emergency procedure to drain a hyperpressure linked to a diabetic foot abscess
2: incision in regard of
the hard instrument
inserted in the abcess
References
1. Debeugny P, Canarelli JP, Bonnevalle M, Besson
R, Ricard J, Herlin P, Ducloux B. Laparoschisis.
Indications for a teon patch in wall repair. Chir
Pediatr. 1990;31(1):18–25.
2. Trupka AW, Schweiberer L, Hallfeldt K, Waldner
H.Management of large abdominal wall hernias with
foreign implant materials (Gore-Tex patch). Zentralbl
Chir. 1997;122(10):879–84.
3. Balén EM, Díez-Caballero A, Hernández-Lizoáin JL,
Pardo F, Torramadé JR, Regueira FM, Cienfuegos
Fig. 15.3 Drainage of an infected DFU
In large abscesses with an infected tense,
inammatory foot showing a single minimal skin
perforation in an interdigital web space, wound
exploration of the depth of the cavity using a forceps measuring the length of undermining is crucial. Usually directed toward the dorsal aspect of
the foot, the forceps can raise the skin at the
extremity. A small incision using a scalpel will
allow a drainage using polyethylene wires, rapidly reducing the tissue damage induced by the
abscess hypertension (Figs.15.2 and 15.3).
JA.Repair of ventral hernias with expanded polytetrauoroethylene patch. Br J Surg. 1998;85(10):1415–8.
https://doi.org/10.1046/j.1365- 2168.1998.00849.x.
4. Vanzi V, Toma E. Deep dissecting haematoma in
patients with dermatoporosis: implications for home
nursing. Br J Community Nurs. 2021;26(Sup3):S6–
S13. https://doi.org/10.12968/bjcn.2021.26.Sup3.S6.
5. Yang K, Graf A, Sanger J.Pressure ulcer reconstruction in patients with heterotopic ossication after spinal cord injury: a case series and review of literature.
J Plast Reconstr Aesthet Surg. 2017;70(4):518–28.
https://doi.org/10.1016/j.bjps.2016.11.026. Epub
2016 Dec 21
6. Cafasso DE, Bowen DK, Kinkennon SA, Stanbro
MD, Kellicut DC. Heterotopic ossicans in chronic
venous insufciency: a new consideration for clinical, aetiology, anatomy and pathophysiology stag-
120
L. Té ot
ing. Phlebology. 2013;28(7):361–5. https://doi.
org/10.1258/phleb.2012.012050. Epub 2013 May 6
7. Hingorani A, LaMuraglia GM, Henke P, Meissner
MH, Loretz L, Zinszer KM, Driver VR, Frykberg R,
Carman TL, Marston W, Mills JL Sr, Murad MH.The
management of diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association
and the Society for Vascular Medicine. J Vasc Surg.
2016;63(2 Suppl):3S–21S. https://doi.org/10.1016/j.
jvs.2015.10.003. PMID: 26804367
8. Duane TM, Huston JM, Collom M, Beyer A, Parli
S, Buckman S, Shapiro M, McDonald A, Diaz J,
Tessier JM, Sanders J. Surgical infection society
2020 updated guidelines on the management of
complicated skin and soft tissue infections. Surg
Infect. 2021;22(4):383–99. https://doi.org/10.1089/
sur.2020.436. Epub 2021 Feb 26
Open Access This chapter is licensed under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License (http://creativecommons.org/licenses/by- nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit
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Telemedicine andSkin Necrosis
AnneDompmartin andVéroniqueHyppolite
16
16.1 Introduction
Tissue death or skin necrosis can occur from an
injury, trauma, radiation treatment, chemical
exposure, or inammatory disease. DNA structure damage appears within the cells, preventing
mitosis which is an essential process of healthy
and normal cell duplication. Removing all the tissue necrosis is mandatory to heal the wound and
prevent infection [1]. The level of tissue necrosis
depends on the etiology of the lesion. Withdrawal
of these tissues can be performed by surgery, but
it may be difcult as necrosis has to be circumscribed. Therefore, nurse care needs to be performed to accelerate the process. Communication
technology devices currently available can adequately support the need of tele-assistance for
this specic wound care.
16.2 Diagnosis ofSkin Necrosis
There are two main types of necrotic tissue present in wounds. One is a dry, thick, leathery tissue,
usually tan, brown, or black in color. The other is
often yellow, slough, tan, green, or brown and
might be moist, loose, and stringy in appearance.
Necrotic tissue will eventually become black,
hard, and leathery. Before any wound care, the
knowledge of the etiology of the skin necrosis is
mandatory. It will guide wound care and global
follow-up of the patient. Management of a
necrotic ulcerated skin tumor (Fig.16.1) is different from a calciphylaxis (Fig.16.2).
Fig. 16.1 Necrotic ulceration of a carcinoma on the dorsum of the hand
A. Dompmartin (*) · V. Hyppolite
Dermatology Department, CHU Caen, Caen, France
e-mail: dompmartin-a@chu-caen.fr;
hyppolite-v@chu-caen.fr
© The Author(s) 2024
L. Téot et al. (eds.), Skin Necrosis, https://doi.org/10.1007/978-3-031-60954-1_16
121
122
Fig. 16.2 Calciphylaxis of the leg in a patient with renal
insufciency
A. Dompmartin and V. Hyppolite
16.4 Technology
Technology is adapted according to the different
countries. Initially only for medical care, it has
been widened to other healthcare professionals to
decrease professional isolation through mutual
aid. It uses a wireless technology, which is an
audiovisual communication system that has the
capacity for synchronous electronic voice and
image transfer. The bedside nurse has a mobile
phone or a computer tablet, and an expert nurse
observes the wound on her computer screen. All
data are transmitted via a secure connection.
The expert nurses are enterostomal therapy
nurses or nurses with strong knowledge (diploma
in wound care) and clinical experience in complex wound care. They need to write reports of
virtual clinical sessions, which are inserted in the
medical le of the patient and sent to all the
healthcare professionals of the patient. Expert
and resource nurses need familiarization with the
service and the related technologies but have also
to be convinced of the importance of secure
transmission of medical data [6].
16.3 Tele-Assistance
Telemedicine can be performed with two modalities: live interactive and store and forward. The
live interactive systems operate in real time and
include a video monitor and high-resolution camera [2–5]. The store and forward technology can
be described as e-mail pictures; the clinical history collected is accompanied by radiologic and/
or photographic images to support the clinical
history. Tele-consultation and tele-assistance
need synchronous communication via video conferencing or telephone calls to allow real-time
interaction between the home nurse and the physician or the expert nurse during the wound care.
The store and forward technology is used for
tele-expertise: dermatoses, interpretation of biologic examinations, etc. There is a need for a
common clear regulation for practicing telemedicine, encompassing privacy issues and data management, and these rules have been established in
most countries.
16.5 Telemedicine andSkin
Necrosis
Prior to the removal of the death tissue, the rst
step is clinical assessment of the necrosis in order
to decide if the necrosis needs to be softened or
hardened before removal. Swelling, edema, and
inammation need to be detected as the main
problems are the underlying tissues, which will
be the bed of wound healing. This rst step is
usually decided in specialized centers before
remote follow-up and wound care analgesia are
prescribed. Acral lesions are usually mummied
so that hard necrosis is circumscribed and comes
off easily (Fig.16.3a, b). Wound care is simple
with dressing that absorbs exudates. Necrosis can
also be softened with hydrogel and removed progressively with a scalpel, on the face, limbs, or
trunk (Fig.16.4). Therefore, the type of wound
care has to be clearly explained to the resource
nurses before the patient comes back home.
16 Telemedicine andSkin Necrosis
Fig. 16.3 Acral necrosis of a patient in intensive care
unit; mummication of the lesions. The aim is to dry and
circumscribe the necrosis. Wound care allowed to cut the
distal necrosis of the nger
123
Tele-assistance is proposed as a remote follow- up to remove necrosis. Removal of skin
necrosis is often difcult at home for bedside
nurses who feel isolated and need clinical support. It is an interventional care that needs a team
to reassure the bedside nurse. It is also an opportunity for the resource nurses to widen their
knowledge and feel more comfortable for wound
debridement. This knowledge transfer is also
closely linked to the rise of professional autonomy and reduces professional isolation. Another
important benet of tele-assistance is to reduce
the travel of patients to hospitals, which promotes
time and cost savings [7, 8].
16.6 Conclusion
Tele-assistance helps to support resource nurses
and improves nurse practice and quality of care.
The resource nurse needs to trust the experience
and the knowledge of the expert nurse or the
medical doctor who assists them remotely.
Contrary to tele-consultation, tele-assistance is
not integrated in most healthcare systems
although the benet is widely recognized.
Removal of skin necrosis that needs specic care
is a good illustration of the interest of remote
wound care assistance.
Fig. 16.4 Necrotic herpes zoster of the face: necrosis has
to be softened and removed with a scalpel
References
1. Mosti G. Wound care in venous ulcers. Phlebology.
2013;28(Suppl 1):79–85.
2. Singh G, Pal US, Mishra M, Gaur A, Pathak D, Singh
YB.Teleassistance and teleconsultation using smart-
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and maxillofacial surgery. Natl J Maxillofac Surg.
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Open Access
NoDerivatives 4.0 International License (http://creativecommons.org/licenses/by- nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit
to the original author(s) and the source, provide a link to the Creative Commons license and indicate if you modied the
licensed material. You do not have permission under this license to share adapted material derived from this chapter or
parts of it.
The images or other third party material in this chapter are included in the chapter's Creative Commons license,
unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons
license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to
obtain permission directly from the copyright holder.
This chapter is licensed under the terms of the Creative Commons Attribution-NonCommercial-
Part III
Skin Necrosis of Toxic Origin
Introduction toSkin Necrosis
ofToxic Origin
SadanoriAkita
17
Medical toxic agents and animal or insect bites
can cause skin necrosis. In addition, there are
clinical and forensic signs of opioid abuse.
Coma-induced blisters are a rare condition associated with prolonged impairment of consciousness levels, which is relatively well known in
adults following an overdose of barbiturates. This
chapter covers skin ulcers and necrosis due to
medications, snakebites, jellysh and stonesh,
spider Loxosceles reclusa, scorpions, and “drugs”
such as Cannabis sativa, cocaine, and heroin. It
also discusses the systemic conditions of the
toxic syndrome and how to resuscitate foot
necrosis. Each theme can bring about a better
understanding of how it develops and how to
treat it properly.
S. Akita (*)
Department of Plastic Surgery, Tamaki-Aozora
Hospital, Tokushima, Japan
Fukushima Medical University, Fukushima, Japan
e-mail: akitas@hf.rim.or.jp
© The Author(s) 2024
L. Téot et al. (eds.), Skin Necrosis, https://doi.org/10.1007/978-3-031-60954-1_17
127