'Flesh-eating' vulva infections reported in three cases — gynecologists should know the signs, experts warn

Gynecologists should be informed of the signs of rare, "flesh-eating" infections, doctors warn, because these dangerous infections can sometimes infiltrate the vulva.

In a new case report published April 8 in the journal BMJ Case Reports, U.K. doctors describe three patients who were found to have necrotizing fasciitis of the vulva. The vulva includes the external female genitalia, such as the labia majora and labia minora, for example.

"Necrotizing fasciitis (NF), also known as flesh-eating disease, can arise when certain bacteria enter the skin through a wound — a cut, abrasion, burn, surgical wound, or even an insect bite," Bill Sullivan, a professor of microbiology and immunology at Indiana University, who was not involved in the case report, told Live Science in an email. "NF can occur anywhere skin or tissue is breached, including genitalia."

In necrotizing fasciitis, bacteria infiltrate the fascia, which is the connective tissue surrounding muscles, nerves, fat and blood vessels. The infection rapidly causes soft tissues to die, or "necrotize," and spreads through the body very quickly.

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The case report authors, who are affiliated with the Shrewsbury and Telford Hospital in England, shared these three cases to notify other gynaecologists of the possibility of vulvar involvement in necrotizing fasciitis cases.

They noted that their hospital has seen a significant uptick in flesh-eating infections in recent years, with 20 cases seen between 2022 and 2024 when only 18 had been reported in the preceding decade. In addition, several EU states and the U.S. have reported increases in invasive group A streptococcus, an infection that can lead to necrotizing fasciitis.

If the infection is becoming more common, doctors should know the importance of rapid treatment, the case report authors emphasized.

"It's an extremely aggressive infection that can advance to a life-threatening situation in 24-48 hours," Sullivan said. "After these bacteria get into the skin, they release potent toxins that lead to rapid tissue destruction, liquefying muscle, nerves, and blood vessels."

The subsequent loss of blood supply to the affected body parts makes treating necrotizing fasciitis with antibiotics difficult, Sullivan explained; infected areas sometimes need to be surgically cut out of the body. Additionally, once the bacteria get into the bloodstream, they can cause sepsis, a dangerous, body-wide immune reaction, potentially leading to organ failure and death.

In the case report, the doctors described the cases of two patients who came to the emergency room with necrotising fasciitis of the vulva, as well as a third who developed the infection following a postoperative wound.

The first patient was alerted to the infection when she found a small spot on her mons pubis — the fatty tissue over the pubic bone. She initially went to her primary care doctor, who prescribed antibiotics. However, the spot worsened over the next five days, which resulted in necrotizing fasciitis that spread to her labia majora, left hip and lower abdomen.

At the ER, the infected tissue was surgically removed, or "debrided." But "despite intensive care unit (ICU) management for systemic infection," the patient died of sepsis only 28 hours after diagnosis.

The second patient came to the ER with a one-week history of having a lump on her labia majora, which turned out to be an infected abscess. Over the next 12 hours, the upper third of her labia majora broke down from necrotizing fasciitis. The patient ultimately needed three debridements to control the infection, after which she underwent reconstructive surgery for the lost tissue. "The wound has since healed well," her doctors noted.

The third patient suffered necrotizing fasciitis after a surgical wound got infected; she had gotten a hysterectomy as a treatment for fibroids. This patient ultimately survived after having the infected tissue surgically removed and being given broad-spectrum antibiotics.

"NF is very rare," and it most often arises in people with conditions that weaken the immune system, such as diabetes or cancer, Sullivan explained. An estimated 700 to 1,200 cases are seen in the U.S. each year. About 500 cases are reported annually in the U.K., or about 0.4 to 0.53 cases per 100,000 people, the case report authors noted.

Vaginal necrotizing fasciitis is even more rare, as people are more likely to have skin injuries on more exposed parts of the body.

"Vaginal NF could be contracted through rough sex, a piercing, or cosmetic and surgical procedures," Sullivan said. "The mortality rate of vaginal NF is estimated to be up to 50%."

The case report authors urged other gynecologists to keep an eye out for any signs of an infection that could develop into necrotizing fasciitis, and they also emphasized that "time is of the essence" when treating the condition.

"Vaginal NF could be considered more dangerous in the sense that it might be more difficult to diagnose in time, " Sullivan said. "Gynecologists may not have NF on their diagnostic radar, and surgical interventions, which are usually required to stop NF from spreading and remove dead tissue, may be limited."

Recognizing the disease quickly is key to saving patients' lives. "Delayed diagnosis can lead to delayed treatment, increasing the odds of sepsis and death," Sullivan said.