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For further information, see CMDT Part 6-33: Infectious Erythemas

Key Features

Essentials of Diagnosis

  • Diffuse, spreading infection of the skin

General Considerations

Cellulitis

  • Usually due to gram-positive cocci, though gram-negative rods or even fungi can produce similar picture

  • The major portal of entry for lower leg cellulitis is toe web tinea pedis with fissuring of the skin at this site

Erysipelas

  • A superficial form of cellulitis that occurs classically on the cheek, caused by β-hemolytic streptococci

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

  • Pain and systemic toxicity may be striking

  • Unlike erysipelas, 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

Clinical Findings

Symptoms and Signs

Cellulitis

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

  • Pain at the lesion, malaise, chills, and moderate fever

  • Usually on the lower leg

  • Septicemia may develop

Erysipelas

  • Central face frequently involved

    • A bright red spot appears first, very often near a fissure at the angle of the nose

    • This 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 somewhat edematous 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

Differential Diagnosis

  • Deep venous thrombosis

  • Venous stasis

  • Candidiasis

  • Anthrax

  • Contact dermatitis

  • Herpes zoster (shingles)

  • Scarlet fever

  • Angioedema

  • Necrotizing fasciitis

  • Sclerosing panniculitis

  • Underlying osteomyelitis

  • Systemic lupus erythematosus

  • Erysipeloid

Diagnosis

Laboratory Tests

  • Attempts to isolate the responsible organism by injecting and then aspirating saline are successful in 20% of cases

  • Leukocytosis and an increased sedimentation rate are almost invariably present but are not specific

  • Blood cultures may be positive

Treatment

Medications

  • Intravenous or parenteral antibiotics effective against group A β-hemolytic streptococci and staphylococci may be required for the first 24–48 hours

  • In mild cases or following the initial parenteral therapy, dicloxacillin or cephalexin, 250–500 mg four times daily orally for 5–10 days, is usually adequate

  • In patients in whom intravenous treatment is not instituted, the first dose of oral antibiotic can be doubled to achieve rapid high blood levels

  • In patients with recurrent lower leg cellulitis, oral penicillin 250 mg twice daily can delay the appearance of the next episode

Erysipelas

  • Place the patient at bed rest with the head of the bed elevated

  • Intravenous antibiotics effective against group ...

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