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Emergency And Acute Medicine - Erysipelas
Basic description
Erysipelas is a superficial bacterial infection of the skin characterized by prominent involvement of the lymphatic system. Leukocytosis is common, and blood cultures are positive in approximately 3–5% of cases.
Etiology
Group A β-hemolytic streptococcus is the most common causative organism, with group C or G streptococci occurring less frequently.
Common portals of entry include skin ulcers, local trauma, abrasions, psoriatic or eczematous lesions, and fungal infections.
Pediatric considerations
Haemophilus influenzae type b can cause facial cellulitis in children that may resemble erysipelas and should be considered in unimmunized patients. Many of these children are bacteremic and require hospital admission with appropriate antibiotic coverage such as cefuroxime. This organism has become far less common with widespread Hib vaccination.
Group B streptococci may cause erysipelas in newborns, often arising from infection of the umbilical stump.
Pregnancy considerations
Erythema of the breast associated with puerperal mastitis is frequently caused by staphylococcal species; coverage for methicillin-resistant Staphylococcus aureus should be considered.
Diagnosis – signs and symptoms
The most commonly affected sites are the lower extremities (70–80%), followed by the face (5–20%) and ears. Facial involvement is often bilateral, whereas involvement elsewhere is typically unilateral. The skin appears intensely erythematous, giving rise to the historical term “Saint Anthony’s fire.”
Erysipelas occurs more often in infants, children, and the elderly. Systemic symptoms may include malaise, fever, chills, nausea, and vomiting. A traumatic portal of entry is not always evident. Rarely, periorbital cellulitis or cavernous sinus involvement may occur.
History
Facial erysipelas may follow nasopharyngeal infection or trauma. The condition has a predilection for areas of lymphatic obstruction, such as the upper extremity after radical mastectomy or the lower extremity after saphenous vein harvesting. It may be a marker of previously unrecognized lymphatic obstruction or congenital lymphedema, such as Milroy disease.
Recurrence occurs in approximately 30% of patients within three years, often due to lymphatic damage from prior episodes.
Physical examination
Affected skin is edematous, indurated with a peau d’orange appearance, painful, and sharply demarcated with raised borders. When involving the face, a classic butterfly distribution over the cheeks and nasal bridge may be seen. Vesicles or bullae can occur in more severe infections.
Essential workup
Diagnosis is clinical, based on characteristic skin findings and the clinical context. Needle aspirate or wound cultures are rarely helpful and are not routinely indicated.
Diagnosis tests and interpretation
Laboratory studies
Skin swabs are not useful, as they typically yield only normal skin flora.
CBC with differential and blood cultures should be obtained in high-risk patients, including those with diabetes, hypotension, or those requiring admission. Blood cultures are more likely to be positive in patients with lymphedema.
Glucose should be checked in diabetics.
Urinalysis may be performed to evaluate for proteinuria, hematuria, or red cell casts, which could suggest post-streptococcal glomerulonephritis, typically occurring about two weeks after infection onset.
Antistreptolysin O and anti-DNase B titers are not helpful in uncomplicated erysipelas and should not be routinely ordered.
Imaging
Routine imaging is not indicated. If deeper infection such as myositis is suspected, plain radiographs or CT may be used to assess for gas. Ultrasound can be helpful to evaluate for abscess or to exclude deep vein thrombosis in the lower extremity.
Differential diagnosis
Abscess
Acute bacterial sinusitis
Allergic inflammation
Cellulitis
Contact dermatitis
Deep vein thrombosis
Inflammatory breast carcinoma
Herpes zoster
Impetigo
Mastitis
Necrotizing fasciitis
Periorbital cellulitis
Systemic lupus erythematosus
Toxic shock syndrome
Venous stasis dermatitis
Viral exanthem
Treatment – prehospital
Use of gloves and appropriate hand hygiene is important to reduce transmission of streptococcal carriage.
Initial stabilization and therapy
Some patients may appear toxic and require intravenous fluids or hemodynamic support.
Emergency department treatment and procedures
Antibiotic therapy should be initiated promptly and continued for approximately 10 days. Patients with extensive disease typically require admission for intravenous antibiotics, with transition to oral therapy once clinically improved.
Mild cases may be treated as outpatients if the patient is nontoxic, reliable, and has close follow-up.
Penicillin is the treatment of choice when erysipelas is clearly diagnosed. If cellulitis cannot be excluded, add staphylococcal coverage with a penicillinase-resistant penicillin or first-generation cephalosporin.
In areas with high MRSA prevalence, vancomycin or other appropriate agents should be considered.
Acetaminophen may be used for fever.
Hospitalized patients should be placed on isolation precautions, as the condition is contagious.
Medication
Outpatient therapy
Penicillin V, amoxicillin, clindamycin, dicloxacillin, erythromycin, cephalexin, or cefuroxime for 10 days, with pediatric dosing adjusted by weight.
Inpatient therapy
Penicillin G IV or IM, clindamycin IV, or vancomycin IV depending on severity, allergy status, and local resistance patterns.
First-line therapy
Penicillin or a first-generation cephalosporin (oral or IV).
Clindamycin for penicillin-allergic patients.
Second-line therapy
Erythromycin.
Follow-up and disposition
Admission criteria
Extensive involvement, fever, toxic appearance, suspected orbital or periorbital cellulitis, inability to tolerate oral therapy, unreliable follow-up, or unimmunized children requiring coverage for H. influenzae.
Discharge criteria
Minimal facial involvement, nontoxic appearance, no immunosuppression, ability to tolerate oral therapy, reliable follow-up, and a clear diagnosis.
Issues for referral
Nephrology referral is indicated if urinalysis shows findings suggestive of post-streptococcal glomerulonephritis, particularly in children.
Infectious disease consultation is recommended for immunocompromised patients or unusual organisms.
Follow-up recommendations
Compression stockings may reduce recurrence in patients with lower-extremity lymphedema.
Treat underlying tinea pedis with topical antifungals to reduce relapse risk.
Clinical pearls and common missteps
Failure to improve or pain disproportionate to exam findings should prompt evaluation for necrotizing fasciitis or deeper infection.
Managing underlying lymphedema reduces recurrence risk.
Micropustules suggest staphylococcal infection rather than erysipelas and warrant broader antibiotic coverage.
Crepitus should raise concern for an alternative diagnosis.
Always assess tetanus immunization status and update as needed.
Consider prophylactic antibiotics in patients with frequent recurrences.
Basic description
Erysipelas is a superficial bacterial infection of the skin characterized by prominent involvement of the lymphatic system. Leukocytosis is common, and blood cultures are positive in approximately 3–5% of cases.
Etiology
Group A β-hemolytic streptococcus is the most common causative organism, with group C or G streptococci occurring less frequently.
Common portals of entry include skin ulcers, local trauma, abrasions, psoriatic or eczematous lesions, and fungal infections.
Pediatric considerations
Haemophilus influenzae type b can cause facial cellulitis in children that may resemble erysipelas and should be considered in unimmunized patients. Many of these children are bacteremic and require hospital admission with appropriate antibiotic coverage such as cefuroxime. This organism has become far less common with widespread Hib vaccination.
Group B streptococci may cause erysipelas in newborns, often arising from infection of the umbilical stump.
Pregnancy considerations
Erythema of the breast associated with puerperal mastitis is frequently caused by staphylococcal species; coverage for methicillin-resistant Staphylococcus aureus should be considered.
Diagnosis – signs and symptoms
The most commonly affected sites are the lower extremities (70–80%), followed by the face (5–20%) and ears. Facial involvement is often bilateral, whereas involvement elsewhere is typically unilateral. The skin appears intensely erythematous, giving rise to the historical term “Saint Anthony’s fire.”
Erysipelas occurs more often in infants, children, and the elderly. Systemic symptoms may include malaise, fever, chills, nausea, and vomiting. A traumatic portal of entry is not always evident. Rarely, periorbital cellulitis or cavernous sinus involvement may occur.
History
Facial erysipelas may follow nasopharyngeal infection or trauma. The condition has a predilection for areas of lymphatic obstruction, such as the upper extremity after radical mastectomy or the lower extremity after saphenous vein harvesting. It may be a marker of previously unrecognized lymphatic obstruction or congenital lymphedema, such as Milroy disease.
Recurrence occurs in approximately 30% of patients within three years, often due to lymphatic damage from prior episodes.
Physical examination
Affected skin is edematous, indurated with a peau d’orange appearance, painful, and sharply demarcated with raised borders. When involving the face, a classic butterfly distribution over the cheeks and nasal bridge may be seen. Vesicles or bullae can occur in more severe infections.
Essential workup
Diagnosis is clinical, based on characteristic skin findings and the clinical context. Needle aspirate or wound cultures are rarely helpful and are not routinely indicated.
Diagnosis tests and interpretation
Laboratory studies
Skin swabs are not useful, as they typically yield only normal skin flora.
CBC with differential and blood cultures should be obtained in high-risk patients, including those with diabetes, hypotension, or those requiring admission. Blood cultures are more likely to be positive in patients with lymphedema.
Glucose should be checked in diabetics.
Urinalysis may be performed to evaluate for proteinuria, hematuria, or red cell casts, which could suggest post-streptococcal glomerulonephritis, typically occurring about two weeks after infection onset.
Antistreptolysin O and anti-DNase B titers are not helpful in uncomplicated erysipelas and should not be routinely ordered.
Imaging
Routine imaging is not indicated. If deeper infection such as myositis is suspected, plain radiographs or CT may be used to assess for gas. Ultrasound can be helpful to evaluate for abscess or to exclude deep vein thrombosis in the lower extremity.
Differential diagnosis
Abscess
Acute bacterial sinusitis
Allergic inflammation
Cellulitis
Contact dermatitis
Deep vein thrombosis
Inflammatory breast carcinoma
Herpes zoster
Impetigo
Mastitis
Necrotizing fasciitis
Periorbital cellulitis
Systemic lupus erythematosus
Toxic shock syndrome
Venous stasis dermatitis
Viral exanthem
Treatment – prehospital
Use of gloves and appropriate hand hygiene is important to reduce transmission of streptococcal carriage.
Initial stabilization and therapy
Some patients may appear toxic and require intravenous fluids or hemodynamic support.
Emergency department treatment and procedures
Antibiotic therapy should be initiated promptly and continued for approximately 10 days. Patients with extensive disease typically require admission for intravenous antibiotics, with transition to oral therapy once clinically improved.
Mild cases may be treated as outpatients if the patient is nontoxic, reliable, and has close follow-up.
Penicillin is the treatment of choice when erysipelas is clearly diagnosed. If cellulitis cannot be excluded, add staphylococcal coverage with a penicillinase-resistant penicillin or first-generation cephalosporin.
In areas with high MRSA prevalence, vancomycin or other appropriate agents should be considered.
Acetaminophen may be used for fever.
Hospitalized patients should be placed on isolation precautions, as the condition is contagious.
Medication
Outpatient therapy
Penicillin V, amoxicillin, clindamycin, dicloxacillin, erythromycin, cephalexin, or cefuroxime for 10 days, with pediatric dosing adjusted by weight.
Inpatient therapy
Penicillin G IV or IM, clindamycin IV, or vancomycin IV depending on severity, allergy status, and local resistance patterns.
First-line therapy
Penicillin or a first-generation cephalosporin (oral or IV).
Clindamycin for penicillin-allergic patients.
Second-line therapy
Erythromycin.
Follow-up and disposition
Admission criteria
Extensive involvement, fever, toxic appearance, suspected orbital or periorbital cellulitis, inability to tolerate oral therapy, unreliable follow-up, or unimmunized children requiring coverage for H. influenzae.
Discharge criteria
Minimal facial involvement, nontoxic appearance, no immunosuppression, ability to tolerate oral therapy, reliable follow-up, and a clear diagnosis.
Issues for referral
Nephrology referral is indicated if urinalysis shows findings suggestive of post-streptococcal glomerulonephritis, particularly in children.
Infectious disease consultation is recommended for immunocompromised patients or unusual organisms.
Follow-up recommendations
Compression stockings may reduce recurrence in patients with lower-extremity lymphedema.
Treat underlying tinea pedis with topical antifungals to reduce relapse risk.
Clinical pearls and common missteps
Failure to improve or pain disproportionate to exam findings should prompt evaluation for necrotizing fasciitis or deeper infection.
Managing underlying lymphedema reduces recurrence risk.
Micropustules suggest staphylococcal infection rather than erysipelas and warrant broader antibiotic coverage.
Crepitus should raise concern for an alternative diagnosis.
Always assess tetanus immunization status and update as needed.
Consider prophylactic antibiotics in patients with frequent recurrences.
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