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erythema, edema and warmth. They differ in that erysipelas involves the upper
dermis and superficial lymphatics, whereas cellulitis involves the deeper dermis and
subcutaneous fat. As a result, erysipelas has more distinctive anatomic features
than cellulitis; erysipelas lesions are raised above the level of surrounding skin, and
there is a clear line of demarcation between involved and uninvolved tissue [4].
Classic descriptions of erysipelas note "butterfly" involvement of the face.
Involvement of the ear (Milian's ear sign) is a distinguishing feature for erysipelas,
since this region does not contain deeper dermis tissue. In addition, patients with
erysipelas tend to have acute onset of symptoms with systemic manifestations
including fever and chills; patients with cellulitis tend to have a more indolent
course with development of localized symptoms over a few days' time. Cellulitis
may present with or without purulent drainage or exudate [5].
The lower extremities are the most common site of infection for both erysipelas and
cellulitis (picture 1A-B) [2,6]. Other forms of cellulitis include periorbital cellulitis,
abdominal wall cellulitis (in morbidly obese individuals), buccal cellulitis (usually
due to Haemophilus influenzae) and perianal cellulitis (due to group A beta-
hemolytic streptococcus) [7,8]. (See "Orbital cellulitis".)
Rarely, infections involving the medial third of the face (ie, the areas around the
eyes and nose) can be complicated by septic cavernous thrombosis, since the veins
in this region are valveless (figure 1). (See "Septic dural sinus thrombosis".)
It is important to distinguish between cellulitis and skin abscess. Skin abscess may
present with surrounding cellulitic findings that may delay diagnosis and
appropriate management (eg, surgical incision and drainage). Management of skin
abscess is discussed further separately. (See "Skin abscesses, furuncles, and
carbuncles".)
Cultures of blood, pus, or bullae are more useful and should be performed in
patients with systemic toxicity, extensive skin involvement, underlying
comorbidities (lymphedema, malignancy, neutropenia, immunodeficiency,
splenectomy, diabetes), special exposures (animal bite, water-associated injury) or
recurrent or persistent cellulitis [30,31]. Cultures of swabs from intact skin are not
helpful and should not be performed.
Cultures obtained from patients with lower extremity cellulitis and toe web
intertrigo due to tinea pedis may be useful for identification of pathogenic bacteria
[16]. This was illustrated in a study of 24 patients with cellulitis; 83 percent had
tinea pedis. Cultures of the interdigital spaces yielded beta-hemolytic streptococci,
S. aureus, and gram-negative bacilli (85, 45 and 35 percent of cases, respectively).
In addition, molecular typing of isolates from paired blood and toe web cultures in
two cases demonstrated identical streptococcal strains [32].
Radiographic examination can be a useful tool for excluding occult abscess and for
distinguishing cellulitis from osteomyelitis [33,34]. Radiographic examination
cannot reliably distinguish cellulitis from necrotizing fasciitis or gas gangrene; if
there is clinical suspicion for these entities, radiographic imaging should not delay
surgical intervention [35,36]. (See "Necrotizing infections of the skin and
fascia" and "Clostridial myonecrosis".)
Serology may have a useful diagnostic role in patients with recurrent cellulitis
(see 'Recurrent cellulitis' below).
TREATMENT
Many patients with cellulitis have underlying conditions that predispose them to
developing recurrent cellulitis (these include tinea pedis, lymphedema, and chronic
venous insufficiency). In such patients, treatment be directed at both the cellulitis
and the predisposing condition. Patients with edema may benefit from treatment
with compressive stockings and diuretic therapy. (See "Dermatophyte (tinea)
infections" and "Medical management of lower extremity chronic venous
disease" and "Lymphedema: Prevention and treatment".)
Most patients develop mild cellulitis and can be treated with oral antibiotics;
patients with signs of systemic toxicity or erythema that has progressed rapidly
should be treated initially with parenteral antibiotics.
Purulent — Patients with purulent cellulitis (eg, cellulitis associated with purulent
drainage or exudate, in the absence of a drainable abscess) should be managed
with empiric therapy for infection due to MRSA, pending culture results [5]. Empiric
therapy for infection due to beta-hemolytic streptococci is likely not necessary. In a
study including 422 patients with purulent soft tissue infection, MRSA was the
dominant organism, isolated from 59 percent of patients, followed by MSSA (17
percent); beta-hemolytic streptococci accounted for a much smaller proportion of
these infections (2.6 percent) [51].
Options for empiric oral therapy for treatment of MRSA include (table 1):
Clindamycin
Trimethoprim-sulfamethoxazole
Tetracycline (doxycycline or minocycline)
Linezolid
Additional empiric coverage for MRSA is warranted in patients who do not respond
to initial therapy, patients with signs of systemic illness, patients with recurrent
infection in the setting of underlying predisposing conditions, and patients with a
previous episode of MRSA infection. In addition, empiric coverage for MRSA should
be considered in patients with risk factors for MRSA infection and in communities
where the prevalence of MRSA is greater than 30 percent (table 3) [44,53-56].
Options for empiric oral therapy for treatment of both beta-hemolytic streptococci
and MRSA include (table 4):
Clindamycin
Amoxicillin combined with trimethoprim-sulfamethoxazole
Amoxicillin combined with a tetracycline (doxycycline or minocycline)
Linezolid
Patients with mild infection or those who have improved following initial treatment
with parenteral antibiotic therapy may be treated with oral penicillin (500 mg orally
every six hours), or amoxicillin (500 mg orally every eight hours).
Macrolides (erythromycin 250 mg orally every six hours) have also traditionally
been used but may not be adequate therapy in areas with relatively high resistance
rates among beta-hemolytic streptococci [53,57]. In the setting of beta-lactam
allergy, cephalexin (if the patient can tolerate cephalosporins), clindamycin,
or linezolid may be used [53].
Preventive measures for reducing the spread of staphylococci may be helpful for
reducing risk for recurrent skin infection and are discussed in detail separately.
(See "Prevention and control of methicillin-resistant Staphylococcus aureus in
adults".)
Some clinicians favor serologic testing for beta-hemolytic streptococci to help guide
the choice of suppressive antibiotic therapy. Assays include the anti-streptolysin O
(ASO) reaction, the anti-deoxyribonuclease B test (anti-DNAse B), the anti-
hyaluronidase test (AHT), or the Streptozyme antibody assay [21]. Anti-Dnase B
and AHT responses are more reliable than the ASO response following GAS skin
infections.
Jasonlove16
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