Erysipelas

Key Features

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

• A superficial form of cellulitis (see Cellulitis) that occurs classically on the cheek, caused by beta-hemolytic streptococci

• 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

• Pain, malaise, chills, and moderate fever

• 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 sharp 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

• Erysipeloid

Diagnosis

Laboratory Tests

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

• Blood cultures may be positive

Treatment

Medications

• Intravenous antibiotics effective against group A beta-hemolytic streptococci and staphylococci should be considered, but outpatient treatment with oral antibiotics have 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) four times daily orally

• 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

Outcome

Complications

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

Prognosis

• With appropriate treatment, erysipelas improves rapidly

• Recurrence of erysipelas is uncommon

• The rare infective endocarditis due to E rhusiopathiae may have mortality rates as high as 30–40% despite surgery, even in immunocompetent individuals

When to Refer

• If there is a question about the diagnosis, if recommended therapy is ineffective, or if specialized treatment is necessary

When to Admit

• Severe local symptoms and signs

• Signs of sepsis

• Elevated white blood cell count of 10,000/mcL or more with marked left shift

• Failure to respond to oral antibiotics