PRACTICE DEVELOPMENT

Cellulitis of the lower limbs:

incidence, diagnosis and
management
KEY WORDS Cellulitis is a common clinical condition that is often inaccurately diagnosed. Risk factors
Cellulitis
 for the development of cellulitis include obesity, lymphoedema and lower limb ulceration.
Lower
 limb It is important to accurately diagnose and effectively treat cellulitis in order to provide
Lymphoedema

cost effective care and reduce patient suffering. This article will deliver an overview on the
Skin
 infection
burden of cellulitis, provide information that will aid accurate diagnosis and summarise
current treatment options.

C
ellulitis is an inflammatory skin condition through erythema, swelling, warmth, oedema and
caused by acute infection of the dermal tenderness over the affected area. There is often
and subcutaneous layers of the skin; it is a poorly defined border separating the affected
characterised by a superficial, diffuse, spreading skin from the non-affected skin (Ch’ng and Johar, 2016).
infection without underlying collection of pus. Cellulitis is commonly caused by Streptococcus
Cellulitis is a common diagnosis among inpatients pyogenes or Staphylococcus aureus, which resides
and outpatients as well as in primary care settings in the interdigital spaces, and it most often affects
(Bailey and Kroshinsky, 2011). It accounts for 3% of the lower limbs (Corwin et al, 2005). Hirschmann
attendance to accident and emergency departments and Raugi (2012b) established that 30–80% of
within the UK (Haydock et al, 2007). The prevalence patients with cellulitis had an interdigital skin
of cellulitis is increasing year on year, with the ageing condition, such as eczema, fissures or athletes
population and increasing levels of obesity thought foot. Any disruptions in the protective barrier of
to be contributing to this rise (Hirschmann and the skin surface allow bacteria to invade the body
Raugi, 2012a). and place patients at increased risk of developing
Many practitioners will encounter patients cellulitis.
with suspected cellulitis; however, diagnosing
cellulitis is not always easy. The identification of INCIDENCE
cellulitis is based solely on clinical findings and, The incidence and treatment of cellulitis places
unfortunately, there are several other common a significant burden on the NHS, both in terms
conditions that mimic the clinical signs of cellulitis, of costs and resources. Lower limb cellulitis
creating a potential for misdiagnosis and incorrect accounted for over 55,000 hospital admissions
management (Hirschmann and Raugi, 2012b). in England during 2011–2012 (Health and Social
Hence it is essential that all practitioners are skilled Care Information Centre [HSCIC], 2013), with a
in recognising cellulitis, confirming diagnosis, mean hospital in patient length of stay of 10 days
and that they possess the ability and skills to set (Department of Health [DH], 2006a; Halpern et
appropriate treatment plans. This would ensure all al, 2008); this amounts to over 400,000 bed days a
patients receive timely, effective care to improve year. Annually, the NHS spends £172–254 million
LEANNE ATKIN their health outcomes. on the admission and treatment of patients with
Lecturer Practitioner/Vascular cellulitis (DH, 2006b; Curtis, 2011).
Nurse Specialist, School of
CELLULITIS
Human and Health Sciences,
University of Huddersfield and Cellulitis is an inflammatory skin condition with RISK FACTORS
Mid Yorkshire NHS Trust an infectious origin, classically presenting itself Risk factors for developing cellulitis include older

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 PRACTICE DEVELOPMENT

age, obesity, venous insufficiency, saphenous systemic symptoms may accompany or precede
venectomy (vein harvest for bypass surgery), the acute onset of skin changes. The affected area
trauma, eczema, dermatitis, athletes foot and will be subject to redness, warmth, swelling and
oedema (Hirschmann and Raugi, 2012a). Patients localised tenderness, with the edges of cellulitis
with lymphoedema are especially at risk of ill defined and the affected skin raised, tight
developing cellulitis, due to the disturbances in and shiny (Eagle, 2007; Opoku, 2015). Typically,
lymph drainage and associated localised impaired presentation is unilateral, with bilateral leg
host response to infection (Soo et al, 2008). It is cellulitis being very rare (NICE, 2015).
reported that within a one-year period, 28% of Laboratory investigations can aid diagnosis.
patients with lymphoedema will develop cellulitis, The Clinical Resource Efficiency Support Team
and a quarter of this group will required admission (CREST, 2005) state that although non-specific,
to hospital for treatment with intravenous nearly all patients with cellulitis will have a raised
antibiotics (Soo et al, 2008). Typically, the onset white cell count (WCC) and elevated erythrocyte
of cellulitis is between the ages of 40 and 60 years
(Ellis Simonsen et al, 2006), and cellulitis occurs in
equal frequency in men and women. The highest
predisposing factor for developing cellulites is a
previous episode of cellulitis, with reported annual
recurrence rates of 8–20% (Hirschmann and
Raugi, 2012b).

DIAGNOSIS
Cellulitis is one of the most commonly
misdiagnosed conditions, with as many as one
third of patients being diagnosed incorrectly
(Hirschmann and Raugi, 2012b). In the region of
132,000 bed days and £84.5 million per year are
wasted as a result of inaccurate diagnosis (Levell et
al, 2011). The Levell et al (2011) study also showed
that a third of patients (33%) referred with lower
limb cellulitis had an alternative diagnosis and, of
the confirmed cases of cellulitis, 28% had another
skin condition that if treated simultaneously would
speed recovery and reduce the risk of recurrence.
This misdiagnosis clearly has other impacts
in terms of patient expectations, treatment
delays and wider public health risks due to the
potential inappropriate use of antibiotics. Other
conditions that can mimic the clinical features
of cellulitis include: varicose eczema, venous
hypertension, lipodermatosclerosis, vasculitis,
necrotising fasciitis, deep vein thrombosis,
septic arthritis, acute gout and thrombophlebitis
(National Institute for Health and Care Excellence
[NICE], 2015).
Clinical signs of cellulitis include pyrexia,
general malaise, pain, and patients often feel
generally unwell, reporting chills or sweating Figure 1. Example of checklist (with kind permission from Wounds International
(Gunderson, 2011; Wingfield, 2012). These [Opoku, 2015])

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 PRACTICE DEVELOPMENT

sedimentation rate (ESR) or C-reactive protein Classification of severity can be useful for guiding
(CRP) level and that normal levels of blood admission and treatment decisions. The Eron
inflammatory markers make the diagnosis of classification (Table 1) is used within the CREST
cellulitis less likely. However, a normal WCC guidelines (2005) and the NICE guidelines (2015)
does not exclude cellulitis. Lazzarini et al (2005) for cellulitis.
reported that only 50% of patients admitted with
cellulitis had a raised WCC, and that ESR and TREATMENT
CRP were much more sensitive markers with Staphylococcus aureus is the most common cause
increases observed in 85% and 97% of patients of cellulitis, and has been found to be the causative
respectively. The use of a diagnostic checklist bacteria in 59–76% of cases (Moran et al, 2006; Lee
can help prevent misdiagnosis, with the checklist et al, 2015). Individualised bacterial identification
produced by Opoku (2015) offering an excellent from microbiology is often difficult due to the
practical tool to aid accurate diagnosis (Figure 1). low recovery rate from needle aspirates, skin
biopsies and blood cultures (Jeng et al, 2010). The
CLASSIFICATION choice of which antimicrobial agent to use will be
governed by the suspected bacteria involved and
steered by local antibiotic guidelines. Flucloxacillin
Table 1. The Eron classification adapted from the CREST guidelines (2005) is commonly used as first-line treatment as it
covers both streptococcal and staphylococcal
Classification Description Treatment
infections. Clarithromycin if allergic to penicillin.
Patients have no signs of
In patients with known lymphoedema, amoxicillin
systemic toxicity, have no
Oral antibiotic therapy is more effective if there is no evidence of
uncontrolled comorbidities
I Identification and management folliculitis, pus formation or crusted dermatitis
and can usually be managed
of underlying risk factors (British Lymphology Society, 2015; NICE, 2015).
with oral antimicrobials on
an outpatient basis Antibiotics should be used for a period of 7 days.
Patients are either
Before commencing treatment, if possible, mark
systemically ill or the area around the extent of the infection with an
systemically well but Requires IV antibiotics. appropriate skin marker, as this can be useful for
with a comorbidity such Admission may not be monitoring responses to antibiotics (NICE, 2015).
a peripheral vascular necessary if there are suitable All patients should be reviewed after 48 hours of
II
disease, chronic venous facilities and expertise in commencing treatment, either face to face or by
insufficiency or morbid community telephone, depending on clinical judgement, to
obesity which may assess the effectiveness of the management plan.
complicate or delay
resolution of their infection
COMPRESSION IN CELLULITIS
Patients may have Patients with venous ulceration are at higher risk
significant systemic of developing cellulitis due to the breakdown
symptoms, such as acute
of the protective barrier of the skin, and these
confusion, tachycardia,
patients are often in compression therapy to
tachypnoea, hypotension; Admit to hospital for IV
treat the underlying venous hypertension. It is
III or may have unstable antibiotics and careful
comorbidities that may monitoring
commonly thought that it is contraindicated to
interfere with a response continue compression therapy when patients
to therapy; or a limb- have an acute infection, and in many patients
threatening infection due to compression therapy is routinely stopped if
vascular compromise there is evidence of acute cellulites. This is not
Patients have sepsis definitive, and in fact there is an argument for the
Admit to hospital for IV
syndrome or severe life- need of continued compression. In each episode
IV antibiotics and treatment of
threatening infections, such of cellulitis the lymphatic system is challenged,
sepsis.
as necrotising fasciitis and cellulitis can result in permanent damage to

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