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Erysipelas

BASICS

DESCRIPTION

  • Acute superficial bacterial skin infection with well-demarcated erythema and lymphatic involvement.
  • Most commonly caused by Group A Streptococcus (Streptococcus pyogenes).
  • Can be acute or chronic recurrent.
  • Nonpurulent infection.
  • Affects skin and exocrine system.

EPIDEMIOLOGY

  • Predominantly affects infants, children, adults >45 years; greatest incidence in elderly (>75 years).
  • No gender or racial predilection.
  • Incidence: ~24 per 1,000 persons/year; increasing since 1980s.
  • Prevalence unknown.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Caused by Group A β-hemolytic streptococci (mostly S. pyogenes), sometimes groups C/G.
  • Rarely group B streptococci or Staphylococcus aureus.
  • Infection triggers inflammatory cascade involving:
  • Contact system activation → proinflammatory cytokines, proteinases, bradykinin release.
  • M protein interaction with neutrophils → heparin-binding protein secretion → vascular leakage.
  • Result: fever, pain, erythema, edema.

RISK FACTORS

  • Disruption of skin barrier (incisions, bites, trauma, dermatophytes, IV drug use).
  • Chronic illnesses: diabetes, malnutrition, nephrotic syndrome, heart failure.
  • Immunocompromise (e.g., HIV).
  • Skin fissures (nose, ears).
  • Toe-web intertrigo, lymphedema, leg ulcers, venous insufficiency.
  • Alcohol abuse, morbid obesity.
  • Recent streptococcal pharyngitis, varicella infection.

GENERAL PREVENTION

  • Good skin hygiene.
  • Manage predisposing conditions (e.g., tinea pedis, stasis dermatitis).
  • Avoid shaving face within 5 days of facial erysipelas (risk of recurrence).
  • Compression stockings for lower extremity edema.
  • Consider prophylactic penicillin in recurrent cases (>2 episodes/year).

PEDIATRIC CONSIDERATIONS

  • Group B Streptococcus may cause erysipelas in neonates and infants.

DIAGNOSIS

HISTORY

  • Prodromal symptoms: moderate to high fever, chills, headache, malaise, anorexia, vomiting, arthralgia.
  • Importance of differentiating from MRSA (which has indurated centers and abscess formation).

PHYSICAL EXAM

  • Fever and tachycardia common; hypotension possible.
  • Acute onset of painful, well-demarcated erythematous plaque with peau d’orange appearance.
  • Milian ear sign (ear involvement indicates erysipelas vs cellulitis).
  • Possible vesicles, bullae, desquamation.
  • Lymphangitis and regional lymphadenopathy.
  • Commonly unilateral; lower extremities (70-80%) > face (5-20%).
  • Chronic form may recur at previous site.
  • Steroid use may mask signs.
  • In elderly, facial butterfly pattern and lymphangitic streaking common.

DIFFERENTIAL DIAGNOSIS

  • Cellulitis (less distinct margins, no ear involvement).
  • Necrotizing fasciitis (severe pain, systemic illness).
  • Skin abscess.
  • Deep vein thrombosis.
  • Acute gout, insect bites, dermatophytes.
  • Impetigo, ecthyma.
  • Herpes zoster, erythema annulare centrifugum.
  • Contact dermatitis, giant cell urticaria.
  • Angioneurotic edema, scarlet fever, toxic shock syndrome.
  • Lupus, polychondritis.
  • Other bacterial infections from animal bites, water exposure.

DIAGNOSTIC TESTS

  • Reserved for severe or immunocompromised patients or treatment failures.
  • Leukocytosis, elevated ESR and CRP common.
  • Blood cultures rarely positive (<5%).
  • Cultures from exudate or noninvolved sites may isolate streptococci.
  • Biopsy not routine: shows dermal/epidermal edema, vasodilation, neutrophilic infiltrates, M protein effects.

TREATMENT

GENERAL MEASURES

  • Symptomatic treatment: fever, myalgia, hydration, cold compresses, limb elevation.
  • Manage underlying risk factors.

MEDICATION

First Line - Adults

  • Extremities, nondiabetic:
  • Penicillin G 1-2 million units IV q6h or cefazolin 1 g IV q8h.
  • Penicillin allergic: Vancomycin 15 mg/kg IV q12h.
  • Switch to oral TMP-SMX or clindamycin when afebrile to complete 10 days.

Early mild disease (diabetics)

  • TMP-SMX DS 1-2 tabs PO BID plus penicillin VK 500 mg or cephalexin 500 mg PO QID.

Severe disease

  • Meropenem, ertapenem, linezolid, vancomycin, or daptomycin IV as needed.

Facial erysipelas

  • Vancomycin 15 mg/kg IV q8-12h (target trough 15-20).
  • Alternatives: daptomycin or linezolid IV.

CHILDREN

  • Penicillin G (dose varies by age and weight).
  • Cefazolin also used.
  • No reported Group A streptococcal resistance to β-lactams.

RECURRENT CASES

  • Prophylactic Penicillin G benzathine 1.2 million U IM q4wk or penicillin VK 500 mg BID or azithromycin 250 mg QD.

ADDITIONAL THERAPIES

  • Topical 1% hydrocortisone trial if worsening symptoms after antibiotics.

ADMISSION CRITERIA

  • Systemic toxicity.
  • High-risk patients (elderly, lymphedema, postsplenectomy, diabetes).
  • Failed outpatient therapy.
  • IV therapy if unable to tolerate PO.

ONGOING CARE

FOLLOW-UP

  • Bed rest and limb elevation during acute phase; resume activity as tolerated.

PROGNOSIS

  • Usually full recovery with treatment.
  • Skin erythema may worsen initially after antibiotics.
  • Most improve within 24-48 hours.
  • Mortality <1% with appropriate therapy.
  • Bullae indicate longer course and possible S. aureus coinfection.

COMPLICATIONS

  • Recurrent infection.
  • Abscess formation (suggests staphylococcal involvement).
  • Necrotizing fasciitis.
  • Lymphedema (risk factor for recurrence).
  • Bacteremia/sepsis.
  • Pneumonia, meningitis due to sepsis.
  • Embolism, gangrene.
  • Septic bursitis, arthritis, tendinitis, osteitis.

REFERENCES

  1. Jendoubi F, Rohde M, Prinz JC. Intracellular streptococcal uptake and persistence: a potential cause of erysipelas recurrence. Front Med. 2019;6:6.
  2. Breen JO. Skin and soft tissue infections in immunocompetent patients. Am Fam Physician. 2010;81(7):893-899.
  3. Inghammar M, Rasmussen M, Linder A. Recurrent erysipelas—risk factors and clinical presentation. BMC Infect Dis. 2014;14:270.

CODES

  • ICD10 A46 Erysipelas

CLINICAL PEARLS

  • Athlete’s foot is the most common portal of entry.
  • Erysipelas distinguished from cellulitis by sharp, shiny, fiery-red raised borders.
  • Most cases now affect the legs rather than the face.
  • In recurrent cases, evaluate for other sources such as tonsils, sinuses, or intertrigo.