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Erysipelas
Fozia Akhtar Ali, MD
Mary Anne de la Cruz Estacio, DO
image BASICS
DESCRIPTION
  • Distinct form of cellulitis notable for acute, well-demarcated, superficial bacterial skin infection with lymphatic involvement almost always caused by Streptococcus pyogenes
  • Usually acute, but a chronic recurrent form also exists (1)
  • Nonpurulent
  • System(s) affected: skin, exocrine
  • Synonym(s): St. Anthony's Fire
EPIDEMIOLOGY
  • Predominant age: infants, children, and adults >40 years
  • Greatest in elderly (>75 years)
  • No gender/racial predilection
  • Affects all races
Incidence
  • Erysipelas occurs in ˜1/1,000 persons/year (2).
  • Incidence on the rise since the 1980s (3)
Prevalence
Unknown
ETIOLOGY AND PATHOPHYSIOLOGY
  • Group A streptococci induce inflammation and activation of the contact system, a proinflammatory pathway with antithrombotic activity, releasing proteinases and proinflammatory cytokines.
  • The generation of antibacterial peptides and the release of bradykinin, a proinflammatory peptide, increase vascular permeability and induce fever and pain.
  • The M proteins from the group A streptococcal cell wall interact with neutrophils, leading to the secretion of heparin-binding protein, an inflammatory mediator that also induces vascular leakage.
  • This cascade of reactions leads to the symptoms seen in erysipelas: fever, pain, erythema, and edema.
  • Group A &bgr;-hemolytic streptococci primarily; commonly S. pyogenes, occasionally, other Streptococcus groups C/G
  • Rarely, group B streptococci/Staphylococcus aureus may be involved.
RISK FACTORS
  • Disruption in the skin barrier (surgical incisions, insect bites, eczematous lesions, local trauma, abrasions, dermatophytic infections, intravenous drug user [IVDU])
  • Chronic diseases (diabetes, malnutrition, nephrotic syndrome, heart failure)
  • Immunocompromised (HIV)/debilitated
  • Fissured skin (especially at the nose and ears)
  • Toe-web intertrigo and lymphedema (2)
  • Leg ulcers/stasis dermatitis
  • Venous/Lymphatic insufficiency (saphenectomy, varicose veins of leg, phlebitis, radiotherapy, mastectomy, lymphadenectomy)
  • Alcohol abuse
  • Morbid obesity
  • Recent streptococcal pharyngitis
  • Varicella
GENERAL PREVENTION
  • Good skin hygiene
  • It is recommended that predisposing medical conditions, such as tinea pedis and stasis dermatitis, be appropriately managed first.
  • Men who shave within 5 days of facial erysipelas are more likely to have a recurrence.
  • With recurrences, search for other possible sources of streptococcal infection (e.g., tonsils, sinuses).
  • Compression stockings should be encouraged for patients with lower extremity edema.
  • Consider suppressive prophylactic antibiotic therapy, such as penicillin, in patients with >2 episodes in a 12-month period.
Pediatric Considerations
Group B Streptococcus may be a cause of erysipelas in neonates/infants.
image DIAGNOSIS
Prodromal symptoms before the skin eruption of erysipelas may include:
  • Moderate- to high-grade fever
  • Chills
  • Headache
  • Malaise
  • Anorexia, usually in the first 48 hours (4)[B]
  • Vomiting
  • Arthralgias
PHYSICAL EXAM
  • Vital signs: moderate- to high-grade fever with resultant tachycardia. Hypotension may occur.
  • The presence of a fever in erysipelas can be considered a differentiating factor from other skin infections.
  • Headache and vomiting may be prominent.
  • Acute onset of intense erythema; well-demarcated painful plaque (5)
  • Peau d'orange appearance
  • Milian's ear sign (erythema involves skin of ear as well as face implies erysipelas)
  • Vesicles and bullae may form but are not uniformly present.
  • Desquamation may occur later.
  • Lymphangitis
  • Location
    • Lower extremity 70-80% of cases
    • Face involvement is less common (5-20%), especially nose and ears.
    • Chronic form usually recurs at site of the previous infection and may recur years after initial episode.
  • Patients on systemic steroids may be more difficult to diagnose because signs and symptoms of the infection may be masked by anti-inflammatory action of the steroids.
  • Systemic toxicity resolves rapidly with treatment; skin lesions desquamate on days 5 to 10 but usually heal without scarring.
  • In geriatric patients, facial involvement presents in a butterfly pattern. Pustules characteristically absent and regional lymphadenopathy with lymphangitic streaking is seen.
Pediatric Considerations
  • Abdominal involvement is more common in infants, especially around umbilical stump.
  • Face, scalp, and leg involvement are common in older children due to the excoriations of anterior rhinitis sicca allowing an easy port of entry.
Geriatric Considerations
  • Fever may not be as prominent.
  • Face and lower extremity are the most common areas.
  • High-output cardiac failure may occur in debilitated patients with underlying cardiac disease.
  • More susceptible to complications
DIFFERENTIAL DIAGNOSIS
  • Cellulitis (margins are less clear and does not involve ear)
  • Necrotizing fasciitis (systemic illness and more pain)
  • Skin abscess (feel for area of fluctuance)
  • DVT (need to rule out if clinically suspected)
  • Acute gout (check patient history)
  • Insect bite (check patient history)
  • Dermatophytes
  • Impetigo (blistered/crusted appearance; superficial)
  • Ecthyma (ulcerative impetigo)
  • Herpes zoster (dermatomal distribution)
  • Erythema annulare centrifugum (raised pink-red ring/bull's-eye marks)
  • Contact dermatitis (no fever, pruritic, not painful)
  • Giant cell urticaria (transient, wheal-appearance, severe itching)
  • Angioneurotic edema (no fever)
  • Scarlet fever (widespread rash with indistinct borders and without edema; rash is most common early in skin folds; develops generalized “sandpaper” feeling as it progresses)
  • Toxic shock syndrome (diffuse erythema with evidence of multiorgan involvement)
  • Lupus (of the face; less fever, positive antinuclear antibodies)
  • Polychondritis (common site is the ear)
  • Other bacterial infections to consider:
    • Meat, shellfish, fish, and poultry workers: Erysipelothrix rhusiopathiae (known as erysipeloid)
    • Human bite: Eikenella corrodens
    • Cat/dog bite: Pasteurella multocida/Capnocytophaga canimorsus
    • Salt water exposure: Vibrio vulnificus
    • Fresh/brackish water exposure: Aeromonas hydrophilia
DIAGNOSTIC TESTS & INTERPRETATION
Reserve diagnostic tests for severely ill, toxic patients, or those who are immunosuppressed.
Initial Tests (lab, imaging)
  • Leukocytosis
  • Blood culture (<5% positive)
  • Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
  • Streptococci may be cultured from exudate/noninvolved sites.
P.359

Test Interpretation
Biopsy is not needed. However, skin findings would show
  • Dermal and epidermal edema, extending into the SC tissues
  • Peau d'orange appearance caused by edema in the superficial tissue surrounding the hair follicles
  • Vasodilation and enlarged lymphatics
  • Mixed interstitial infiltrate mainly consisting of neutrophils and mononuclear cells
  • Endothelial cell swelling
  • Gram-positive cocci in lymphatics and tissue with rare invasion of local blood vessels
  • Fibrotic thickening of lymphatic vessel walls with possible luminal occlusion may be seen in recurrent erysipelas.
image TREATMENT
GENERAL MEASURES
  • Symptomatic treatment of myalgias and fever
  • Adequate fluid intake
  • Local treatment with cold compresses
  • Elevation of affected extremity
  • Appropriate therapy for any underlying predisposing condition
MEDICATION
  • Antibiotics cure 50-100% of infections, but which regimen is most successful is unclear
  • Antibiotics may be as effective when given orally versus intravenously.
  • A 5-day course of antibiotics may be as effective as a 10-day course at curing (6)[A].
First Line
  • Adults
    • Extremities, nondiabetic
      • Primary
        • Penicillin G: 1 to 2 million U IV q6h or cefazolin 1 g IV q8h
      • Alternative (if penicillin-allergic)
        • Vancomycin 15 mg/kg IV q12h
        • When afebrile Pen VK 500 mg PO QID AC and HS
    • Total 10 days, diabetics
      • Early-mild:
        • Trimethoprim-sulfamethoxazole (TMP-SMX)-DS: 1 to 2 tabs PO BID and penicillin VK 500 mg PO QID or cephalexin 500 mg PO QID
    • Severe disease
      • IMP or MER or ERTA IV and linezolid 600 mg IV/PO BID. or vancomycin IV or daptomycin 4 mg/kg IV q24h
    • Facial
      • Primary
        • Vancomycin: 15 mg/kg (actual weight) IV q8-12h with target trough 15 to 20
      • Alternative
        • Daptomycin 4 mg/kg IV q24h or linezolid: 600 mg IV q12h
  • Children
    • Penicillin G
      • 0 to 7 days, <2,000 g: 50,000 U/kg q12h
      • 8 to 28 days, <2,000 g: 75,000 U/kg q8h
      • 0 to 7 days, >2,000 g = 50,000 U/kg q8h
      • 8 to 28 day, >2,000 g = 50,000 U/kg q6h
      • >28 days to 50,000 U/kg per day
    • Cefazolin
      • 0 to 7 days, <2,000 g: 25 mg/kg q12h
      • 8 to 28 days, <2,000 g: 25 mg/kg q12h
      • 0 to 7 days, >2,000 g = 25 mg/kg q12h
      • 8 to 28 day, >2,000 g = 25 mg/kg q8h
      • >28 days to 25 mg/kg q8h
  • No reported group A streptococci resistance to &bgr;-lactam antibiotics
  • In chronic recurrent infections, prophylactic treatment after the acute infection resolves:
    • Penicillin G benzathine: 1.2 million U IM q4wks or penicillin VK 500 mg PO BID or azithromycin 250 mg PO QD
  • If staphylococcal infection is suspected or if patient is acutely ill, consider a &bgr;-lactamase-stable antibiotic.
  • Consider community-acquired MRSA, and depending on regional sensitivity, may treat MRSA with TMP-SMX DS 1 tab PO BID or vancomycin 1 g IV q12h or doxycycline 100 mg PO BID
ISSUES FOR REFERRAL
Recurrent infection, treatment failure
ADDITIONAL THERAPIES
Some patients may notice a deepening of erythema after initiating antimicrobial therapy. This may be due to the destruction of pathogens that release enzymes, increasing local inflammation. In this case, treatment with corticosteroids, in addition to antimicrobials, can mildly reduce healing time and antibiotic duration in patients with erysipelas. Consider prednisolone 30 mg/day with taper over 8 days (7).
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Patient with systemic toxicity
  • Patient with high-risk factors (e.g., elderly, lymphedema, postsplenectomy, diabetes)
  • Failed outpatient care
IV Fluids
IV therapy if systemic toxicity/unable to tolerate PO
Discharge Criteria
No evidence of systemic toxicity with resolution of erythema and swelling
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Bed rest with elevation of extremity during acute infection, then activity as tolerated
Patient Monitoring
Patients should be treated until all symptoms and skin manifestations have resolved.
PATIENT EDUCATION
Stress importance of completing prescribed medication regimen
PROGNOSIS
  • Patients should recover fully if adequately treated.
  • May experience deepening of erythema after initiation of antibiotics
  • Most respond to therapy after 24 to 48 hours.
  • Mortality is <1% in patients receiving appropriate treatment.
  • Bullae formation suggests longer disease course, and often indicates a concomitant S. aureus infection that may require antibiotic coverage for MRSA.
  • Chronic edema/scarring may result from chronic recurrent cases.
  • Rarely, obstructive lymphadenitis may result from chronic recurrent cases.
REFERENCES
1. Gabillot-Carré M, Roujeau JC. Acute bacterial skin infections and cellulitis. Curr Opin Infect Dis. 2007;20(2):118-123.
2. Bernard P. Management of common bacterial infections of the skin. Curr Opin Infect Dis. 2008;21(2):122-128.
3. Celestin R, Brown J, Kihiczak G, et al. Erysipelas: a common potentially dangerous infection. Acta Dermatovenerol Alp Pannonica Adriat. 2007;16(3):123-127.
4. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-1406.
5. Breen JO. Skin and soft tissue infections in immunocompetent patients. Am Fam Physician. 2010;81(7): 893-899.
6. Morris AD. Cellulitis and erysipelas. BMJ Clin Evid. 2008;2008:1708.
7. Bergkvist PI, Sjöbeck K. Antibiotic and prednisolone therapy of erysipelas: a randomized, double blind, placebo-controlled study. Scand J Infect Dis. 1997;29(4):377-382.
8. Inghammar M, Rasmussen M, Linder A. Recurrent erysipelas—risk factors and clinical presentation. BMC Infect Dis. 2014;14:270.
Additional Reading
&NA;
Gilbert D, Chambers HF, Eliopoulos GM, et al, eds. The Sanford Guide to Antimicrobial Therapy. 44th ed. Sperryville, VA: Sanford Guides; 2014.
Codes
&NA;
ICD10
A46 Erysipelas
Clinical Pearls
&NA;
  • Athlete's foot is the most common portal of entry.
  • Erysipelas is distinguished from cellulitis by its sharp, shiny, fiery-red, raised border.
  • In recurrent cases, search for other possible source of streptococcal infection (e.g., tonsils, sinuses, intertrigo).
  • Most erysipelas infections now occur on the legs, rather than the face.