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I appreciate Dr Gallego pointing out a very difficult area in the differential diagnosis of necrotizing fasciitis. The text of my article might have read "erysipelas, as opposed to necrotizing fasciitis, usually lacks bullae and necrosis."Interestingly, a synonym for necrotizing fasciitis in the older literature is "gangrenous erysipelas." Several standard textbooks admittedly do state that occasionally bullae and rarely necrosis are seen in erysipelas. Bullae and necrosis, however, in an erysipelas-like lesion, greatly increase the likelihood of necrotizing fasciitis. Because these two conditions are so similar, the clinician is obligated to distinguish between the two with a biopsy. As cited in my article, a biopsy in necrotizing fasciitis, whether incisional or excisional, will establish the diagnosis by exposing an undermined, necrotic fascia, as well as a greasy, serosanguineous exudate.I agree with Dr Gallego that because of the more serious prognosis of necrotizing fasciitis, the distinction between the two diseases is of critical
Koehn GG. Necrotizing Fasciitis-Reply. Arch Dermatol. 1979;115(4):507. doi:10.1001/archderm.1979.04010040079027