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Spider bites as the cause of necrotic skin and soft tissue lesions occur very rarely in Central and Northern Europe. Recluse spiders, distributed almost worldwide, are one of two genera of spiders with confirmed capability of causing necrotic lesions. In the facial region, the resulting defects represent a potential reconstructive challenge, especially in younger patients.
This case report has been reported in line with the SCARE criteria.
We describe a case of a 19-year-old female with a suspected bite from a recluse spider sustained during a recreational trip to Guatemala. She was bitten on the right upper aspect of the nose, and within a week developed a large necrotic lesion extending to the medial canthus. Following her return to Denmark the defect was reconstructed with a trimmed full-thickness skin graft. An initially planned second-stage reconstructive procedure was cancelled, as the patient was satisfied with the primary result.
Most aspects of the extended reconstructive ladder were evaluated before selecting the optimal reconstruction for this patient. In younger patients, reconstructive surgery requires special considerations, primarily due to age-related limitations combined with generally high expectations to the aesthetic outcome.
In the few reported cases of necrotic spider bites in the facial region, active reconstructive measures have resulted in the best outcomes. Tissue expansion of local or regional skin may have a potential role, but in certain patients, simple reconstructive solutions will provide an aesthetically satisfactory result without requiring extensive or multi-stage surgeries, as demonstrated in this case.
Medical doctors in Central and Northern Europe are highly unlikely to encounter necrotic skin and soft tissue lesions caused by spider bites. Most reported cases of confirmed or suspected spider bites resulting in necrotic lesions, have been from North and South America , . In Europe, the very few cases in comparison have mainly been from Mediterranean countries , .
Recluse spiders, distributed almost worldwide, are one of only two genera of spiders with confirmed capability of causing necrotic lesions through their bite and venom , , , , . They belong to the genus Loxosceles, with the brown recluse spider Loxosceles reclusa the species most extensively described (Fig. 1). Of relevance to this case, several species of recluse spiders are native to Guatemala .
Venom from these spiders contains the cytotoxic enzyme Sphingomyelin phosphodiesterase. The enzyme breaks down sphingomyelin and lysophosphatidylcholine  – major constituents of the cell membrane – giving rise to local inflammation resulting in endothelial damage, polymorphonuclear leukocyte infiltration and degranulation into the envenomation site, causing microvascular thrombosis, ischemia and potentially skin necrosis , .
Resulting defects in the facial region represent potential reconstructive challenges, especially in younger patients, due to age-related limitations of regional flap donor sites, increased demand for minimal scarring, and generally high expectations to the aesthetic outcome.
In a case from a university hospital, we outline the process, and discuss the considerations pertaining to reconstruction of a large facial skin defect in a young woman following a suspected recluse spider bite.
This case report has been reported in line with the SCARE criteria .
A 19-year-old Caucasian female was referred to the Department of Plastic Surgery, Breast Surgery and Burns Treatment, Rigshospitalet, Copenhagen University Hospital, on the day of her return to Denmark from a recreational trip to Guatemala.
The patient presented with a soft tissue defect on the right upper aspect of the nose extending to the medial canthus, completely exposing the underlying muscles (Fig. 3A). She informed that she had recently received treatment for a suspected spider bite.
Twelve days prior to her return to Denmark she reported waking up in the morning, scratching her nose because of an itching, tickling sensation. She initially did not feel any discomfort or pain and did not see a spider, but was aware she had been bitten by something. During the following two days she experienced increasing pain at the bite site and developed local swelling and redness, which soon spread to the rest of the cheek and periorbital area. The bite site turned necrotic during the second day (Fig. 2).
One week after the bite the patient was seen at a local Guatemalan hospital, where medical doctors examined the necrotic lesion and made a clinical diagnosis of a spider bite, based on the initial presentation and progression of the lesion. She underwent surgery twice with local excision of the necrotic tissue and revision of the defect.
On her return to Denmark she was feeling well with no signs or symptoms of general illness. The defect measured approximately 37 × 37 millimeters, involving the right upper dorsal part of the nose, extending laterally to the infraorbital margin, and reaching within a few millimeters to the medial canthus. The underlying muscles were visible and confined the deep extension of the defect (Fig. 3A). She was still taking a twelve-hourly prophylactic dose of oral Azithromycin 500 mg prescribed by the medical doctors in Guatemala. There were no signs of ongoing infection in the defect or surrounding tissue. A wound swab culture revealed no pathogenic bacteria, including MRSA.
We decided to offer the patient surgical reconstruction scheduled shortly after her return.
A two-stage reconstruction was initially planned using a trimmed full-thickness skin graft (FTSG) harvested from the proximal, medial aspect of the thigh to provide a temporary cover for future second-stage reconstruction with a skin graft or flap more closely resembling the nasal skin, likely after tissue expansion of local or regional skin.
First stage of the planned reconstruction took place 14 days after the patient's return to Denmark, to ensure that any remaining inflammatory reaction from the spider venom had subsided, and any foreign bacterial colonization or subclinical infection, including MRSA, had been cleared. The defect had healed well from initial presentation but far from completely, measuring approximately 17 × 19 millimeters after gentle wound revision prior to skin grafting (Fig. 3B).
A FTSG was harvested and trimmed to match the thickness and level of the skin surrounding the defect. It was secured to the margins of the defect with single interrupted 6-0 PROLENE® sutures and covered with a sterile dressing.
The patient was referred to the outpatient clinic for dressing and suture removal at five days postoperatively, where the skin graft appeared vital with no signs of skin necrosis or infection (Fig. 4). At follow-up three months (Fig. 5A) and 14 months (Fig. 5B) after the first and so far final stage of reconstruction, the trimmed FTSG had engrafted nicely with only slightly raised edges and minor color mismatch to the surrounding skin.
The patient was satisfied with the result. She could completely conceal the scars with make-up, and did not request further reconstructive surgery.
Necrotic lesions in the facial region caused by spider bites are an uncommon presentation. A case series by Wright et al.  including 111 patients reported the anatomical distribution of suspected and confirmed brown recluse spider bites. They dominated on the extremities (78%) with the face amounting to just 3%. Of the 111 patients only three (2.7%) required skin grafting, of whom none had facial lesions.
Conservative initial management with RICE (Rest, Ice, Compression, Elevation) and healing by secondary intention if necroses develop, seems generally agreed upon , . However, healing by secondary intention has unfortunately been shown to be quite slow in many necrotic lesions, taking several weeks or months. Moreover, the vast majority of the patients reported did not have lesions on the face, which makes it difficult to justify generalization of conservative treatment principles, when based almost exclusively on non-facial lesions.
Defects in the facial region can be aesthetically disfiguring, and often require active reconstructive measures when long-lasting conservative management is unacceptable for the patient.
In six reported cases of necrotic lesions in the facial region caused by recluse spider bites (four on the eyelid, one on the chin and one on the ear), two patients underwent active reconstruction with a local flap and delayed suturing respectively, following an initial bout of healing by secondary intention. Complete healing in these two cases happened in 2 and 3 weeks respectively , . Time to complete healing in the remaining four cases exclusively let to heal by secondary intention, was 2 months (one patient; healed with no scarring ) and 6 months respectively (three patients; healed with scarring , ).
Thus considerations were many in planning the optimal reconstructive course for our patient.
First of all the patient was very young and exhibited age-related insufficient skin laxity for local flap reconstruction, and lacked wrinkle lines to conceal a donor site scar, e.g. if using a paramedian forehead flap. Secondly, selecting the optimal donor site outside areas of aesthetic concern for a probable skin graft reconstruction also demanded consideration. Finally the patient requested the minimal amount of surgery required.
Most aspects of the extended reconstructive ladder were evaluated before finally selecting the optimal reconstruction: Healing by secondary intention and direct suturing were both considered suboptimal solutions in the present case. The former due to the anticipated extensive scar formation and potential discomfort to the patient. The size of the defect meant direct suturing was impossible.
Tissue expansion of regional skin, in this case pre-expansion of a hairless part of post-auricular skin, had initially been planned in order to provide a FTSG more closely resembling the periorbito-nasal skin (when compared to classic donor sites not requiring pre-expansion, such as the skin overlying the clavicles) for a second-stage resurfacing of the defect. The plan was abandoned on the day of surgery as the defect had decreased to a size where the risks and potential complications of expander implantation outweighed the benefits.
Consequently, we decided to reconstruct the defect with a simple skin graft from a donor site not necessitating pre-expansion. The proximal, medial aspect of the thigh was considered a suitable donor site, as an area of less aesthetic concern with scars easily concealed. A FTSG with the dermis trimmed to match the thickness and level of the surrounding skin was considered the optimal solution for a first-stage reconstruction. The possibility also existed that it could serve as a standalone final reconstruction.
In the few reported cases of necrotic spider bites in the facial region, active reconstructive measures have resulted in the best outcomes. In younger patients the reconstructive options are limited, primarily due to age-related factors. Tissue expansion of local or regional skin may have a potential role, but in certain patients simple reconstructive solutions will provide an aesthetically satisfactory result without requiring extensive or multi-stage surgeries, as demonstrated in this case.
Joachim Mikkelsen: conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the article, revising the article critically for important intellectual content, final approval of the version to be submitted.
Grethe Schmidt: conception and design of the study, acquisition of data, analysis and interpretation of data, revising the article critically for important intellectual content, final approval of the version to be submitted.
Rikke Holmgaard: conception and design of the study, analysis and interpretation of data, drafting the article, revising the article critically for important intellectual content, final approval of the version to be submitted.
Written and informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
The authors would like to thank Richard S. Vetter, M.S., Staff Research Associate at the Department of Entomology, University of California, Riverside, for permission to use his photograph of a brown recluse spider (Fig. 1) in this article.