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Dutta et al. Plast Aesthet Res 2018;5:20 I http://dx.doi.org/10.20517/2347-9264.2018.19 Page 7 of 9
[25]
saline solution emitted from the tip of a hand-held instrument . The jet travels through the nozzle of the
instrument generating a Venturi effect which is an increase in the fluid’s velocity and a decrease in its static
[26]
pressure due to its passage through a constricted area . Here, in this case, we have used jet force technology
(JFT), which is a type of hydrotherapy previously studied extensively in our department and shown to
be an effective means to debride the wounds without the mess of traditional methods and hasten wound
[27]
healing . It uses a disposable cannula , saline and oxygen under high pressure to mechanically remove
the debris and bacteria, with addition of giving positive pressure oxygen therapy to the wound. Utilizing a
unique triple nozzle, JFT is one of the simplest, most efficient and effective methods to do fast and virtually
painless debridement when compared to other mechanical debridement methods.

[28]
Role of topical phenytoin in dental socket healing had been established since 1958 . Further studies have
proven its efficacy in foot venous ulcers and diabetic foot wounds. The mechanism of action of topical
phenytoin is still one of the mysteries of medical science. It has been postulated to cause a proliferation of
human fibroblasts and keratinocytes while reducing the incidence of gram negative bacterial growth on the
wound. Local pain relief has also been observed with topical phenytoin therapy, which can be explained
by its membrane-stabilizing action. Systemic effects are not yet been reported with topical phenytoin
application.

Topical Insulin therapy exerts its effects via IGF 1 receptor. Use of topical insulin in diabetic foot has shown
to produce faster epithelization rates. Insulin has been known to stimulate keratinocytes and the rate of
[29]
endothelial proliferation leading to faster neovascularization and formation of granulation tissue .

These novel modalities are some very efficacious additives in this situation which can drastically reduce the
burden and morbidity of a severely debilitating condition like FG with a very high rate of mortality. Efficacy
of these modalities individually has been proven in modalities like burns, chronic wounds, diabetic foot
ulcers in various studies.

As it is seen in this case report, the results achieved with these interventions together were astounding and
further studies with a large sample size are needed to prove the same. The benefits of these interventions are
that these are cost effective, innovative and easy to do in most centers around the world.

Hope our experience with this condition will promote innovation among the medical fraternity all over the
world and efforts for more such novel modalities to get desired results.

In conclusion, FG is a serious surgical disease with a high mortality and morbidity. Early rehabilitation of a
patient with Fournier’s gangrene involves aggressive surgical intervention together with fluid, hemodynamic
and nutritional support and broad-spectrum/targeted antibiotics, but a majority of the burden of hospital
stay is wasted in wound bed preparation. This case emphasizes the importance of these simple, cost effective
novel adjuncts like LLLT, APRP, hydrojet debridement, topical insulin and phenytoin therapy and the use
of collagen dressing in accelerating wound bed preparation and decreasing the overall hospital stay and
treatment costs.

DECLARATIONS
Authors’ contributions
Concept and design: Dutta S, Chittoria RK
Data acquisition and analysis, manuscript preparation: Dutta S, Aggarwal A

Critical revision and finalizing of the manuscript: Chittoria RK, Subbarayan E, ChavanV,Reddy KS, Gupta S,
Reddy CL