SIGNS AND SYMPTOMS 
- Most common sites of involvement are the face (5–20% of cases), lower legs (70–80% of cases), and ears
- Skin has an intense fiery red color, hence the name "Saint Anthony's fire"
- Often bilateral on the face, but unilateral elsewhere
- Predilection for infants, children, and the elderly
- Systemic symptoms may include malaise, fever, chills, nausea, and vomiting
- Traumatic portal of entry on skin is not always apparent
- Rarely there may be an associated periorbital cellulitis or cavernous sinus involvement
History
- Facial erysipelas may follow a nasopharyngeal infection or trauma
- Predilection for areas of lymphatic obstruction:
- Particularly in the upper extremity following radical mastectomy
- Increased frequency after saphenous vein harvesting or stripping
- May be a marker for previously undiagnosed lymphatic obstruction, or patients with congenital lymphedema (such as Milroy disease)
- 30% recurrence rate within 3 yr, owing to lymphatic obstruction caused by an episode of erysipelas
Physical Exam
- Involved skin is:
- Edematous
- Indurated (peau d'orange)
- Painful
- Well-circumscribed plaque with sharp, clearly demarcated edges
- Classical butterfly rash on cheeks and across nose when affecting face
- Vesicles and bullae may be present in more serious infections
ESSENTIAL WORKUP
- The diagnosis is clinical:
- Based on the characteristic skin findings and the clinical setting
- Needle-aspirate wound cultures are seldom positive and not indicated
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Swabs of the skin are not indicated for culture, as they will show only skin organisms
- CBC with differential, and blood cultures should be performed in diabetics and other high-risk populations, or in patients with hypotension and those who require admission:
- Blood cultures more likely to be positive in patients with lymphedema
- Check glucose in diabetics as infection may disrupt control
- Urinalysis: To check for proteinuria, hematuria, and red cell casts
- Would suggest diagnosis of post-streptococcal glomerulonephritis (PSGN)
- If it occurs, usually around 2 wk after onset of skin infection
- Antistreptolysin O (ASL-O), anti-DNase B and streptolysin antibody serial titer changes are useful in diagnosing post-streptococcal immunologic entities such as rheumatic fever or glomerulonephritis,
- Do not add anything to the diagnosis and management of uncomplicated erysipelas
- Should not be routinely ordered unless there are already manifestations of such complications
Imaging
- There is no standard imaging for classical erysipelas
- If deeper infection such as myositis is suspected, plain films of an extremity or CT scan may be performed to assess for the presence of gas
- Ultrasound may be useful to evaluate for an abscess if this is suspected, or in the leg to r/o deep vein thrombophlebitis DVT
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
Wearing gloves, followed by hand washing when managing patients, to decrease risk of transmission of streptococcal carriage
INITIAL STABILIZATION/THERAPY
Patients may be toxic and in need of intravenous fluid resuscitation or pressure support
ED TREATMENT/PROCEDURES
- Appropriate antibiotic therapy; treatment should be for 10 days:
- Patients with extensive involvement should be admitted for parenteral antibiotic treatment
- May switch to oral antibiotics when patient is stable and showing signs of response
- Mild cases: Patients can be discharged on oral therapy if nontoxic appearing, good compliance, and close follow-up can be ensured
- Penicillin is the drug of choice when symptoms are consistent with erysipelas
- If there is difficulty in distinguishing from cellulitis, staphylococcal coverage should be added:
- Use penicillinase-resistant penicillin or 1st-generation cephalosporin
- If in community with high incidence of MRSA, use vancomycin, or other anti-MRSA coverage
- Reports of vancomycin-resistant Staphylococci are occurring
- Acetaminophen for fever
- Isolation while in hospital
MEDICATION
OUTPATIENT
- Penicillin V: 500 mg PO q6h (peds: 25–50 mg/kg/d div. q6–8h) for 10 days.
- Amoxicillin: 500 mg PO q8h (peds: 50 mg/kg/d div. TID) for 10 days.
- Clindamycin: 300 mg PO QID (peds: 8–25 mg/kg/d suspension PO div. TID or QID) for 10 days.
- Dicloxacillin: 500 mg PO q6h (peds: 30–50 mg/kg/d PO div. q6h) for 10 days
- Erythromycin: 250–500 mg PO q6h (peds: 40 mg/kg/d PO in div. doses q6h) for 10 days
- Cephalexin: 500 mg PO q6h (peds: 40 mg/kg/d PO div. q8h) for 10 days
- Cefuroxime: 250–500 mg PO BID (peds: 30 mg/kg/d PO div. q12h) for 10 days.
INPATIENT
- Penicillin G: 2 million U q4h IV (peds: 25,000 U/kg IV q6h).
- Penicillin G, procaine: 600,000 U q12h IM
- Clindamycin: 600 mg q8h IV (peds: 20–40 mg/kg/d IV div. q8h)
- Vancomycin: 1 g IV q12h given over 1.5–2 hr to decease risk of red man syndrome (peds: 10–15 mg/kg IV q6h)
First Line
- Oral or IV: Penicillin or 1st-generation cephalosporin
- Clindamycin for penicillin-allergic individuals
Second Line
Oral: Erythromycin
[Outline]
DISPOSITION
Admission Criteria
- Patients with extensive involvement, fever, toxic appearance, or in whom orbital or periorbital cellulitis is suspected
- Patients who live alone or are unable or unreliable to take oral medications will require admission for IV antibiotics
- Children more often require admission
- Blood cultures
- Intravenous antibiotics, including coverage for H. influenzae, should be initiated for patients who have not been immunized with HIB vaccine
Discharge Criteria
- Minimal facial involvement
- Nontoxic appearance
- Not immunosuppressed
- Able to tolerate and comply with oral therapy
- Adequate follow-up and supervision
- Diagnosis certain
Issues for Referral
- Refer to nephrologist for evaluation and treatment for PSGN if:
- Hematuria, proteinuria, and red cell casts are noted on UA
- Particularly in children between the ages of 5 and 15
- Infectious disease consultation for infection in immunocompromised patients who are at risk for unusual organisms
FOLLOW-UP RECOMMENDATIONS
- Use of pressure stocking on leg in the presence of lymphedema may reduce incidence of relapses
- Following erysipelas of legs, use of topical antifungal cream or ointment to treat underlying tinea pedis when present
[Outline]
- Damstra RJ, van Steensel MA, Boomsma JH, et al. Erysipelas as a sign of subclinical primary lymphoedema: A prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg. Br J Dermatol. 2008;158:1210–1215.
- Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64:148–155.
- Kilburn SA, Featherstone P, Higgins B, et al. Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev. 2010;(6):CD004299.
- Morris A. Cellulitis and erysipelas. Clin Evid. 2006;(15):2207–2211.
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