Erysipelas

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Cellulitis and erysipelas are skin infections that

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develop as a result of bacterial entry via breaches in the skin barrier

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The incidence is about

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200 cases per 100,000 patient-years

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CLINICAL MANIFESTATIONS

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skin erythema, edema and warmth in the absence of underlying suppurative foci

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They differ in that erysipelas involves ______, whereas cellulitis involves the _______

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- the upper dermis and superficial lymphatics
- deeper dermis and subcutaneous fat

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Involvement of the ear (Milian's ear sign) is a distinguishing feature for erysipelas since

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this region does not contain deeper dermis tissue.

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site of infection

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lower extremities
periorbital cellulitis, abdominal wall cellulitis (in morbidly obese individuals), buccal cellulitis (usually due to Haemophilus influenzae) and perianal cellulitis (due to group A beta-hemolytic streptococcus)

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Crepitant and gangrenous cellulitis are unusual manifestations of cellulitis due to

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clostridia and other anaerobes.

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Predisposing factors

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disruption to the skin barrier as a result of trauma
inflammation
preexisting skin infection
edema

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DIFFERENTIAL DIAGNOSIS

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necrotizing fasciitis, gas gangrene, toxic shock syndrome, bursitis, osteomyelitis, herpes zoster, and erythema migrans

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DIAGNOSIS

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clinical manifestations
Blood cultures are positive in less than 5 percent of cases

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Cultures of blood, pus, or bullae are more useful and should be performed in patients with

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systemic toxicity, extensive skin involvement, underlying comorbidities (lymphedema, malignancy, neutropenia, immunodeficiency, splenectomy, diabetes), special exposures (animal bite, water-associated injury) or recurrent or persistent cellulitis

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Radiographic examination is

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not necessary for routine evaluation of patients with cellulitis

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MICROBIOLOGY

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beta-hemolytic streptococci (groups A, B, C, G, and F); other pathogens include Staphylococcus aureus, including methicillin-resistant strains (MRSA) and gram-negative aerobic bacilli

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Less common pathogens include

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Haemophilus influenzae (buccal cellulitis), clostridia and non-spore-forming anaerobes (crepitant cellulitis), pneumococcus and meningococcus

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TREATMENT

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treatment of underlying conditions
Elevation
The skin should be sufficiently hydrated
Antibiotics

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Antibiotics

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ceftriaxone (1 g intravenously every 24 hours) or
cefazolin (1 to 2 g intravenously every 8 hours)

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Antibiotics

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ceftriaxone (1 g intravenously every 24 hours) or
cefazolin (1 to 2 g intravenously every 8 hours)

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Patients with classic manifestations of erysipelas and systemic manifestations such as fever and chills should be treated with

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parenteral therapy.

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Patients with classic manifestations of erysipelas and systemic manifestations such as fever and chills should be treated with

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parenteral therapy.

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Patients with mild infection or those who have improved following initial treatment with parenteral antibiotic therapy may be treated with

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oral penicillin (500 mg orally every 6 hours), or amoxicillin (500 mg orally every 8 hours).
Macrolides (erythromycin 250 mg orally every 6 hours)

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Patients with mild infection or those who have improved following initial treatment with parenteral antibiotic therapy may be treated with

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oral penicillin (500 mg orally every 6 hours), or amoxicillin (500 mg orally every 8 hours).
Macrolides (erythromycin 250 mg orally every 6 hours)

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In the setting of beta-lactam allergy,

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cephalexin (if the patient can tolerate cephalosporins), clindamycin, or linezolid may be used

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In the setting of beta-lactam allergy,

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cephalexin (if the patient can tolerate cephalosporins), clindamycin, or linezolid may be used

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Duration

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should be tailored to clinical improvement
Patients treated initially with parenteral therapy with resolving signs of infection may complete antimicrobial therapy with an oral agent.
total duration of antibiotic therapy may extend up to fourteen days

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Duration

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should be tailored to clinical improvement
Patients treated initially with parenteral therapy with resolving signs of infection may complete antimicrobial therapy with an oral agent.
total duration of antibiotic therapy may extend up to fourteen days

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Follow-up

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symptomatic improvement within 24 to 48 hours of beginning antimicrobial therapy, although visible improvement of clinical manifestations may take up to 72 hours

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Follow-up

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symptomatic improvement within 24 to 48 hours of beginning antimicrobial therapy, although visible improvement of clinical manifestations may take up to 72 hours

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RECURRENT CELLULITIS

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Suppressive therapy may be continued for several months with interval assessment for relapse.
We suggest suppressive antibiotic therapy for patients with recurrent cellulitis who have predisposing factors that cannot be alleviated

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RECURRENT CELLULITIS

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Suppressive therapy may be continued for several months with interval assessment for relapse.
We suggest suppressive antibiotic therapy for patients with recurrent cellulitis who have predisposing factors that cannot be alleviated