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Erysipelas and cellulitis

Paraclinical investigations

Treatment

Last updated: October 2020

Acute skin infections, due to bacteria (usually Group A beta-haemolytic streptococcus and sometimes
Staphylococcus aureus, including methicillin resistant S. aureus–MRSA) that enter through a break in
the skin.
The main risk factors are: venous insufficiency, obesity, oedema or lymphoedema, history of
erysipelas or cellulitis, immunosuppression and cutaneous inflammation (e.g. dermatosis, wound).
Erysipelas is a superficial infection (affecting the dermis and superficial lymph vessels), while cellulitis
affects the deeper tissues (deep dermis layers and subcutaneous fat).
Generally, these infections affect the lower extremities and sometimes the face. If the orbital and
periorbital tissues are infected, see Periorbital and orbital cellulitis, Chapter 5. If the infection is
perifollicular, see Furuncles and carbuncles, Chapter 4.

Clinical signs
Warm, tender, swollen well–demarcated erythematous plaque.
Fever, lymphadenopathy and lymphangitis.
Look for a portal of entry (bite, ulcer, wound, intertrigo, eczema, fungal infection, etc.).
In case of intense pain disproportionate to the skin lesion, hypoesthesia, rapidly progressing local
signs, crepitation, skin necrosis or critically ill appearing patient, consider necrotising fasciitis that
is a surgical emergency (see Necrotising infections of the skin and soft tissues, Chapter 10).
Other complications: septicaemia (see Septic shock, Chapter 1), acute glomerulonephritis,
osteomyelitis, septic arthritis.
The main differential diagnoses include: contact dermatitis, stasis dermatitis due to venous
insufficiency, venous thrombosis and erythema migrans characteristic of Lyme disease.

Paraclinical investigations
Ultrasound: can detect signs of cellulitis and rule out an underlying abscess, deep vein thrombosis
or a foreign body.
Radiography: can detect a foreign body, underlying osteomyelitis (or gas in the subcutaneous
tissue in case of a necrotising infection, nevertheless the absence of gas does not rule out this
diagnosis).

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Test for proteinuria with urine dipstick 3 weeks after infection to look for glomerulonephritis.

Treatment
In all cases:
Outline the area of erythema with a pen in order to follow the infection a .
Bed rest, elevation of affected area (e.g. leg).
Treatment of pain (Chapter 1). Avoid NSAIDs that may increase the risk of necrotising fasciitis.
Administer antibiotics: either orally or IV depending on severity.
Treat portal of entry and comorbidities.
Check and/or catch up tetanus vaccination (see Tetanus, Chapter 7).
In case of necrotising fasciitis, septic arthritis or osteomyelitis: urgent transfer to a surgical
centre, initiate IV antibiotic treatment while awaiting transfer.

Hospitalize for the following: children younger than 3 months, critically ill appearing patient b , local
complications, debilitated patient (chronic conditions, the elderly) or if there is a risk of non-
compliance with or failure of outpatient treatment. Treat other patients as outpatients.

Outpatient antibiotherapy c :
cefalexin PO for 7 to 10 days
Children 1 month to under 12 years: 25 mg/kg 2 times daily
Children 12 years and over and adults: 1 g 2 times daily
or
amoxicillin/clavulanic acid (co-amoxiclav) PO for 7 to 10 days.
Use formulations in a ratio of 8:1 or 7:1. The dose is expressed in amoxicillin:
Children < 40 kg: 25 mg/kg 2 times daily
Children ≥ 40 kg and adults:
Ratio 8:1: 2000 mg daily (2 tablets of 500/62.5 mg 2 times daily)
Ratio 7:1: 1750 mg daily (1 tablet of 875/125 mg 2 times daily)
In the event of worsening clinical signs after 48 hours of antibiotic treatment, consider IV route.

Inpatient antibiotherapy d :
First line therapy:
cloxacillin IV infusion over 60 minutes e
Children 1 month to under 12 years: 12.5 to 25 mg/kg every 6 hours
Children 12 years and over and adults: 1 g every 6 hours
or
amoxicillin/clavulanic acid (co-amoxiclav) by slow IV injection (3 minutes) or IV infusion (30
minutes). The dose is expressed in amoxicillin:
Children under 3 months: 30 mg/kg every 12 hours
Children 3 months and over: 20 to 30 mg/kg every 8 hours (max. 3 g daily)
Adults: 1 g every 8 hours

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If there is clinical improvement after 48 hours (afebrile and erythema and oedema have
improved) switch to cefalexin or amoxicillin/clavulanic acid PO at the doses indicated above to
complete 7 to 10 days of treatment.
If there is no clinical improvement after 48 hours, consider MRSA:
clindamycin IV infusion over 30 minutes f
Children 1 month and over: 10 mg/kg every 8 hours
Adults: 600 mg every 8 hours
After 48 hours, change to clindamycin PO at the doses indicated above to complete 7 to 10
days of treatment.

Footnotes
(a) The erythema will regress if the treatment is effective. If the erythema spreads consider a treatment failure
(MRSA or a necrotising infection).

(b) Critically ill appearing child: weak grunting or crying, drowsy and difficult to arouse, does not smile, disconjugate
or anxious gaze, pallor or cyanosis, general hypotonia.

(c) For penicillin-allergic patients, clindamycin PO for 7 to 10 days (children: 10 mg/kg 3 times daily; adults: 600 mg
3 times daily).

(d) For penicillin-allergic patients, clindamycin IV infusion (children: 10 mg/kg 3 times daily; adults: 600 mg 3 times
daily).

(e) Cloxacillin powder for injection should be reconstituted in 4 ml of water for injection. Then dilute each dose of
cloxacillin in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kg and in a bag of 100 ml
of 0.9% sodium chloride or 5% glucose in children 20 kg and over and in adults.

(f) Dilute each dose of clindamycin in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kg
and in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children 20 kg and over and in adults.

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