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For further information, see CMDT Part 6-30: 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 patch 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 advances noticeably in days or even hours

  • The lesion has 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

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

  • Clindamycin (250 mg twice daily orally for 7–14 days) is an alternative for penicillin-allergic patients

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 (10 × 109/L) or more with marked left shift

  • Failure to respond to oral antibiotics

REFERENCE

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Ren  Z  et al. Burden, risk factors, and infectious complications of cellulitis ...

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