Doctors in Saudi Arabia report that an obese woman who had shaved her perineal area – before applying a topical herbal substance provided by an alternative practitioner – developed aggressive necrotising fasciitis a week later.
MedPage Today reports that what ensued was a 12-week hospitalisation for surgical debridement and numerous wound therapy interventions, according to Ali Bassi, MD, MSc, and Futoon Alsaleh, MD, of King Saud University in Riyadh, who described the case in the American Journal of Case Reports.
They noted that this type of infection predominantly affects males and immunocompromised individuals. While she was obese, the patient had a functioning immune system.
“This case highlights that Fournier gangrene (an aggressive form of necrotising fasciitis that affects the perineum and external genitalia) can occur after minor perineal manipulation in women without immunodeficiency,” they wrote.
About 30% of Fournier gangrene cases occur in otherwise healthy individuals, but have a mortality rate of about 40%, the authors wrote. “When it occurs in women, it may be initially misdiagnosed as a gynaecological condition, which can delay definitive management.”
The shaving and application of the herbal topical occurred a week before the patient presented with progressive left labial pain and swelling, vomiting and lower abdominal pain, they added.
Bassi told MedPage Today that the patient did not identify the herbal substance that she used. However, he and Alsaleh believe that the combination of perineal shaving, which disrupts the skin barrier, and the subsequent application of a non-sterile topical preparation, may have created a portal of entry for polymicrobial infection.
Both the shaving and the herbal topical substance should be considered as possible contributing factors to the necrotising fasciitis rather than the proven causes, he added.
“The patient’s history of shaving and using non-medical topical preparations suggests possible contamination from unsterilised instruments or herbal compounds, creating conditions favourable for polymicrobial invasion,” they wrote.
Numerous steps were taken to treat the patient after CT imaging, including negative-pressure wound therapy, serial dressing changes, and more surgical debridement under anaesthesia for five of the 12 weeks, according to the report.
A discovered anal fistula was treated with a fistulotomy, although it was unclear if it were a source of the infection or a complication.
Wound cultures revealed E. coli, Klebsiella pneumoniae, and Enterobacter cloacae, which were treated with a variety of antibiotics.
Meropenem was administered after the initial broad-spectrum antibiotics were discontinued, and the patient was ultimately stepped down to amoxicillin-clavulanate.
Bassi told MedPage Today the patient has recovered and regained good function. “But she was left with mild cosmetic deformity from the extensive tissue loss.”
The woman received nutritional counselling focused on high-protein supplementation, and was referred to rehabilitation services for gait disturbances due to perineal scarring, the report stated. Scar revision surgery was planned for a year later.
“Obesity may mask early clinical signs and contribute to diagnostic delay,” the authors wrote, advising that early recognition should result in “prompt imaging, aggressive surgical debridement and multidisciplinary management”.
The most important lesson from this case, Bassi told MedPage Today, is that Fournier gangrene is a clinical diagnosis, not a demographic diagnosis.
“Clinicians should consider it whenever patients present with rapidly progressive perineal pain and swelling, regardless of sex or immune status.”
Study details
Fournier Gangrene in an immunocompetent woman following minor perineal manipulation: a case report
Published in American Journal of Case Reports on 31 July 2026
Ali Bassi and Futoon Alsaleh
Abstract
Background
Fournier gangrene is a rare, life-threatening necrotising fasciitis involving the perineum and external genitalia. It predominantly affects men, while cases in women are uncommon and often under-recognised, leading to delays in diagnosis and treatment. Although Fournier gangrene is frequently associated with immunocompromised states and diabetes mellitus, cases occurring in immunocompetent individuals remain exceptional.
Case report
We report a 40-year-old woman with obesity (BMI 39 kg/m²) and without immunodeficiency who presented with severe left labial pain and swelling one week after perineal shaving and topical herbal application. On examination, she had tachycardia, with marked tenderness and swelling extending to the suprapubic region. Laboratory investigations revealed significant inflammatory response. Computed tomography demonstrated extensive subcutaneous gas and fascial involvement of the vulva and perineum, consistent with necrotising fasciitis. The patient underwent urgent surgical debridement followed by multiple re-explorations and negative-pressure wound therapy. Cultures identified extended-spectrum β-lactamase–producing Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae. Empirical broad-spectrum antibiotics were initiated, and subsequent culture-guided therapy allowed step-down from meropenem to amoxicillin-clavulanate. Definitive wound closure was achieved by secondary intention after prolonged inpatient care.
Conclusions
This case highlights that Fournier gangrene can occur following minor perineal manipulation in women without immunodeficiency. Obesity may mask early clinical signs and contribute to diagnostic delay. Early recognition, prompt imaging, aggressive surgical debridement, and multidisciplinary management remain essential for favourable outcomes, even in patients without classical risk factors. These findings reinforce the need to maintain a high index of suspicion in atypical presentations.
MedPage Today article – A Week After Shaving, She Developed Rare Flesh-Eating Disease (Open access)
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