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1. ERYSIPELAS

ESSENTIALS OF DIAGNOSIS

  • Edematous, circumscribed, hot, erythematous area, with raised advancing border.

  • Central face or lower extremity frequently involved.

  • Pain and systemic toxicity may be striking.

General Considerations

Erysipelas is a superficial form of cellulitis that is caused by beta-hemolytic streptococci.

Clinical Findings

A. Symptoms and Signs

The symptoms are pain, malaise, chills, and moderate fever. A bright red spot appears and then spreads to form a tense, sharply demarcated, glistening, smooth, hot plaque. The margin characteristically makes noticeable advances in days or even hours. The lesion is edematous with a raised edge and may pit slightly with the finger. Vesicles or bullae occasionally develop on the surface. The lesion does not usually become pustular or gangrenous and heals without scar formation. The disease may complicate any break in the skin that provides a portal of entry for the organism. On the face, erysipelas begins near a fissure at the angle of the nose. On the lower extremity, tinea pedis with interdigital fissuring is a common portal of entry.

B. Laboratory Findings

Leukocytosis is almost invariably present; blood cultures may be positive.

Differential Diagnosis

Erysipeloid is a benign bacillary infection producing cellulitis of the skin of the fingers or the backs of the hands in fishermen and meat handlers.

Complications

Unless erysipelas is promptly treated, death may result from bacterial dissemination, particularly in older adults.

Treatment

Intravenous antibiotics effective against group A beta-hemolytic streptococci and staphylococci should be considered, but outpatient treatment with oral antibiotics has demonstrated equal efficacy. Oral regimens include a 7-day course with penicillin VK (250 mg), dicloxacillin (250 mg), or a first-generation cephalosporin (250 mg) orally four times a day. Alternatives in penicillin-allergic patients are clindamycin (250 mg twice daily orally for 7–14 days) or erythromycin (250 mg four times daily orally for 7–14 days), the latter only if the infection is known to be due to streptococci.

Prognosis

With appropriate treatment, rapid improvement is expected. The presence of lymphedema carries the greatest risk of recurrence.

2. CELLULITIS

ESSENTIALS OF DIAGNOSIS

  • Edematous, expanding, erythematous, warm plaque with or without vesicles or bullae.

  • Lower leg is frequently involved.

  • Pain, chills, and fever are commonly present.

  • Septicemia may develop.

General Considerations

Cellulitis, a diffuse spreading infection of the dermis and subcutaneous tissue, is usually on the lower leg (Figure 6–27) and most commonly due to gram-positive cocci, especially group A beta-hemolytic streptococci and S aureus. Rarely, gram-negative rods or even fungi can produce a similar picture. In otherwise healthy persons, the most common portal of entry for lower leg ...

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