2.2.3 Erysipelas

1B70

Cellulitis (in Anglosphere).

Prevalence around 1100 /100.000 per year. 

An acute cutaneous bacterial infection that involves first the superficial lymphatics with fast spreading in the upper dermis and, if not properly treated, may penetrate depending on the virulence of the microbe and the susceptibility of the host into deeper layers including the adipose tissue and fascia and muscle (necrotizing fasciitis).

The site of entry often is in between toes, in skin folds or in superficial erosions. Causative agents are about 90% beta-hemolytic group A streptococci (less B,C,G) or Staphylococcus aureus and sometimes gram-positive or - negative bacteria. 90% are localized at the lower extremity, 2.5% in the face.

Acute illness with fever, chills (often missing in recurrent disease and in the elderly), sharply bordered, warm, tender, oedematous, erythematous plaques with flame-like peripheral spread. Bullous, haemorrhagic or necrotic presentations are more severe variants.

Erysipelas can affect any site, although it has a predilection for the face and legs. Chronic edema of the leg is predisposing. In the face often spreading to the opposite site.

Uncomplicated type, vesicular- bullous or hemorrhagic type, necrotic /gangrenous type. 

Erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) elevated, later ASL/AST titres rises with a leukocytosis.

Dermal edema with dilation of upper and deep vessel plexus. Masses of polymorphous neutrophils between collagen bundles, later with necrotic areas. 

Either short, high fever and fast response to anti-streptococcal antibiotics or complicated when deeper penetrating and host defence is low. 

Lymphoedema (especially with recurrent disease), myocarditis, pneumonia, glomerulonephritis. Sepsis < 5%. Thrombosis (if occurring on the face this can result in venous sinus thrombosis). Abscess formation.

Clinical features (fever, erythema), culture of possible entry point (tinea pedis between the toes or nasal swab), inflammatory markers.

Acute contact dermatitis, thrombophlebitis, erysipeloid, acrodermatitis chronica atrophicans (inflammatory stage), large phlegmon of the lower leg, be careful not to miss necrotising fasciitis.

Bed rest, involved region elevated, cool moist compresses, systemic antibiotics (penicillin 4-5 million IU daily i.v. or 4 x 500 mg oral or amoxicillin in uncomplicated cases, alternatively amoxicillin/clavulanate; severe erysipelas need hospitalization and thrice or four times daily 5 to 10. Mill. Units penicillin, if resistant, cephalosporins) for around 7-10 days. Clindamycin is an alternative, especially if penicillin allergy present.

Necrotizing deep penetrating type with development into necrotizing fasciitis early intervention by surgery.

In severe lymphoedema with relapsing erysipelas maintenance treatment (on/off). Inpatients can be treated with concomitant intermittent lymph-compression during antibiotic infusion.