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 “St. Anthony's fire”
- Often bilateral on the face, but unilateral elsewhere
- Predilection for infants, children, and the elderly
- Prodromal systemic symptoms may include malaise, fever, chills, nausea, and vomiting; skin rash occurs 1-2 d after prodrome
- 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
Diagnostic 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:
- Antistreptolysin O (ASL-O), anti-DNase B and streptolysin antibody serial titer changes are useful in diagnosing poststreptococcal immunologic entities such as rheumatic fever or glomerulonephritis:
- Do not add 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 stand ard 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 thrombosis (DVT)
Differential Diagnosis
- Abscess
- Acute bacterial sinusitis
- Allergic inflammation
- Cellulitis
- Contact dermatitis
- DVT
- Diffuse inflammatory carcinoma of the breast
- Familial Mediterranean fever
- Herpes zoster, second division of cranial nerve V
- Impetigo
- Inflammatory dermatophytosis
- Mastitis
- Necrotizing fasciitis
- Periorbital cellulitis
- Systemic lupus erythematosus (SLE) with butterfly rash
- Streptococcal or staphylococcal TSS (sunburn-like rash)
- Venous stasis dermatitis
- Viral exanthem
Prehospital
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 d
- 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 first-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 d
- Amoxicillin: 500 mg PO q8h (peds: 50 mg/kg/d div. t.i.d) for 10 d
- Clindamycin: 300 mg PO q.i.d (peds: 8-25 mg/kg/d suspension PO div. t.i.d or q.i.d) for 10 d
- Dicloxacillin: 500 mg PO q6h (peds: 30-50 mg/kg/d PO div. q6h) for 10 d
- Erythromycin: 250-500 mg PO q6h (peds: 40 mg/kg/d PO in div. doses q6h) for 10 d
- Cephalexin: 500 mg PO q6h (peds: 40 mg/kg/d PO div. q8h) for 10 d
- Cefuroxime: 250-500 mg PO b.i.d (peds: 30 mg/kg/d PO div. q12h) for 10 d
INPATIENT
- Penicillin G: 2 million units q4h IV (peds: 25,000 units/kg IV q6h)
- Penicillin G, procaine: 600,000-1.2 million units q12h IM
- Clindamycin: 600 mg q8h IV (peds: 20-40 mg/kg/d IV div. q8h)
- Vancomycin: 15 mg/kg IV q12h given over 1.5-2 hr to decrease risk of red man syndrome (peds: 10-15 mg/kg IV q6h)
- Ceftriaxone: 1g IV q24h
- Cefazolin: 1g IV q8h
First Line
- Oral or IV: Penicillin or first-generation cephalosporin
- Clindamycin for penicillin-allergic individuals
Second Line
Oral: Erythromycin
Disposition
Admission Criteria
- Patients with extensive involvement, fever, toxic appearance, or in whom orbital or periorbital cellulitis is suspected
- Underlying immunosuppressive comorbidities (diabetes, alcoholism, immunocompromised)
- Patients who live alone or are unreliable to take oral medications will require admission for IV antibiotics
- Failure of oral antibiotics
- Unable to tolerate oral 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 in 2-3 d 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 5-15
- Infectious disease consultation for infection in immunocompromised patients who are at risk for unusual organisms
Follow-up Recommendations
- Mark outlying edge of infection with skin marker to monitor infection
- 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
- AminAN, CerceoEA, DeitelzweigSB, et al. Hospitalist perspective on the treatment of skin and soft tissue infections . Mayo Clin Proc. 2014;89:1436-1451.
- BläckbergA, TrellK, RasmussenM. Erysipelas, a large retrospective study of aetiology and clinical presentation . BMC Infect Dis. 2015;15:402.
- GundersonCG, MartinelloRA. A systematic review of bacteremias in cellulitis and erysipelas . J Infect. 2012;64:148-155.
- IbrahimF, KhanT, PujalteGG. Bacterial skin infections . Prim Care. 2015;42:485-499.
- InghammarM, RasmussenM, LinderA. Recurrent erysipelas - Risk factors and clinical presentation . BMC Infect Dis. 2014;14:270.
- StevensDL, BisnoAL, ChambersHF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America . Clin Infect Dis. 2014;59(2):e10-e52.
- SukumaranV, SenanayakeS. Bacterial skin and soft tissue infections . Aust Prescr. 2016;39:159-163.
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