Jamal
A Mohammad MD, FRCSC (Canada)*
Salem Al-Ajmi MD
Abdul-Aziz Al-Rasheed MD
*Consultant,
Plastic and Reconstructive Surgeon
Ministry of Health, Kuwait
Email: drjmal
@yahoo.com
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ABSTRACT
Skin carbuncle is a
necrotizing infection of the skin
and subcutaneous tissues, composed
of a cluster of furuncles, usually
due to Staphylococcus aureus, with
multiple drainage sinuses. People
with diabetes are more likely to develop
carbuncles. Broad-spectrum antimicrobial
agents, in conjunction with surgical
intervention, are often necessary
to eradicate these infections. In
this study we present our local experience
in the surgical management of post
carbuncle soft tissue defects in diabetic
patients. The results of the treatment
of 27 patients with a carbuncle of
various locations were analyzed retrospectively.
Twenty-seven patients had surgical
reconstruction of a large post carbuncle
soft tissue defect with split thickness
skin grafts (63%) and local transposition
flaps (37%). Both skin grafts and
local flaps are good alternatives
in the coverage of such defects. However
skin flaps provide better cosmetic
appearance than skin grafts.
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Key Words: carbuncle,
skin graft, skin flap
Carbuncle is an infection
of cutaneous and subcutaneous tissue that
consists of a cluster of boils (1-4). The
infection can occur when a cut, wound, friction,
pressure, or moisture forces the bacteria
deeper into the skin or hair follicle. Carbuncles
are often found on the back of the neck,
shoulders, hips and thighs, and they are
especially common in middle-aged or elderly
men. Commonly, the causative agent is Staphylococcus
aureus (4). Also, with a diagnosis of carbuncle,
it is important to consider whether there
is an underlying condition causing carbuncle,
such as diabetes mellitus (5-10). The elevated
serum glucose levels of diabetics affect
traditional host defenses, predisposing
these individuals to infectious processes.
The diabetic patient is also faced with
disturbance of their immune systems which
can alter host defense mechanisms and increase
the risk of infection (10). Infections in
diabetics can be severe and life-threatening,
and only through the prompt recognition
and treatment of these disorders can morbidity
and mortality be avoided.
Appropriate treatment principles consist
of adequate surgical drainage of pus, excision
of all necrotic tissues and adequate coverage
with broad spectrum antibiotics.
In certain cases where
there are large soft tissue defects following
surgical debridement of the localized skin
infection, direct surgical closure is not
possible. In this case surgical closure
requires either skin grafting or local transposition
of nearby skin flaps. Choice of surgical
tissue coverage depends on the soft tissue
size, location, and involvements of major
body vital structures. Split thickness skin
grafts are simple and heal faster. Patients,
however are not always satisfied with theire
aesthetic skin results. Localized skin flaps
provide a better choice for skin and soft
tissue coverage of post carbuncle defects.
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The data consists of
all diabetic patients transferred and admitted
from 2002 till 2006 with a diagnosis of
post carbuncle soft tissue defect. There
were 27 patients; 19 male (70%) and 8 female
(30%). The average age was 52 years old.
The post carbuncle soft tissue defect was
larger for direct primary closure, as shown
in Figs 1-4. The most
common bacterial organism was Staphylococcus
aureus. In a few patients, mixed bacterial
organisms were seen with gram negative and
methicillin resistant Staphylococcus aureus
(MRSA). Each patient received a full course
of intravenous broad spectrum antibiotic,
based on the organism sensitivity laboratory
results. Split-thickness skin grafting was
performed in the majority of cases (63%)
(Fig 3) whereas local
transposition skin flaps was performed in
(37%) (Fig 4). All skin
grafts and local skin flaps healed without
significant healing complications.
Skin carbuncle is a skin
infection larger than a boil and with several
openings for discharge of pus. The main
causative organism of carbuncle is by a
bacterium, Staphylococcus aureus, which
infects an area under the skin or in a hair
follicle. (1-3) Carbuncles occur more often
in men because of their more extensive body
hair growth (4). A differential approach
to choice of surgical method with consideration
of the degree, phase and localization of
inflammation is preferable. Early and radical
surgery, antimicrobial drugs, and infusion
therapy, provide up-to-date and adequate
treatment. All of these infections are typically
diagnosed by clinical presentation and treated
empirically. If antibiotics are required,
one that is active against gram-positive
organisms such as penicillinase-resistant
penicillin's, cephalosporins, macrolides,
or fluoroquinolones should be chosen. Children,
patients who have diabetes or patients who
have immunodeficiencies are more susceptible
to gram-negative infections and may require
treatment with a second- or third-generation
cephalosporin.
Diabetes mellitus is
believed to increase susceptibility to infectious
diseases (5-9). The effects of hyperglycemia
per se on infectious disease risk are unknown
and the influence of diabetes on infectious
disease outcome is controversial. The production
of humoral antibody appears intact, defective
function of the polymorphonuclear leucocytes
has been demonstrated (9-10).
Successful treatment
of infections in the diabetic requires early
and exact diagnosis, the exhibition of the
correct antimicrobials, the treatment of
the diabetic state and associated disorders
and prompt surgical intervention where required.
Good control of blood glucose in diabetic
patients is a desirable goal in the prevention
of certain infections and to ensure maintenance
of normal host defense mechanisms that determine
resistance and response to infection (10).
In certain cases, large
soft tissue defects exist following surgical
excision of the carbuncle. Such defects
require soft tissue coverage, once the infectious
process has settled. Split thickness skin
grafts serve as a simple quick surgical
solution for certain defects, however, local
flaps can cover such defects effectively
with better cosmetic results than split
thickness skin grafts.
Carbuncle in diabetic
patients can result in significant soft
tissue defects of the involved skin region.
Following proper diagnosis and management,
surgical reconstruction of such defects
can be simple with skin grafts. However,
transposition of local skin flaps gives
better durable soft tissue coverage with
better cosmetic outcome.
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