What is the treatment for Erysipelas (Erythema infectiosum)?

From the Guidelines

Erysipelas treatment should prioritize antibiotics targeting Group A Streptococcus, with oral penicillin V or amoxicillin recommended for mild cases, and intravenous penicillin G or ceftriaxone for severe cases requiring hospitalization. The treatment approach should be based on the severity of the infection and the patient's allergy status. For patients with penicillin allergy, alternative options such as clindamycin or macrolides like azithromycin can be considered 1. It is essential to note that erysipelas is a distinct condition from erysipeloid, which is caused by Erysipelothrix rhusiopathiae and typically affects individuals who handle fish, marine animals, swine, or poultry 1.

Key Considerations

• Erysipelas is primarily caused by Group A Streptococcus, and treatment should target this organism 1.
• Mild cases can be treated with oral antibiotics, while severe cases require hospitalization and intravenous antibiotics 1.
• Patients with penicillin allergy should be treated with alternative antibiotics, such as clindamycin or macrolides 1.
• Erysipeloid, caused by Erysipelothrix rhusiopathiae, is a distinct condition that requires different treatment approaches, including penicillin, cephalosporins, clindamycin, or fluoroquinolones 1.

Treatment Recommendations

• Oral penicillin V (500 mg four times daily for 7-10 days) or amoxicillin (500 mg three times daily for 7-10 days) for mild cases.
• Intravenous penicillin G (2-4 million units every 4-6 hours) or ceftriaxone (1-2 g daily) for severe cases requiring hospitalization.
• Clindamycin (300-450 mg four times daily) or macrolides like azithromycin (500 mg on day 1, then 250 mg daily for 4 days) for patients with penicillin allergy.

Additional Measures

• Patients should elevate the affected area, apply cool compresses for comfort, and take acetaminophen or ibuprofen for pain and fever.
• Adequate hydration is essential, and treatment should continue until clinical improvement is evident, typically with reduced redness, swelling, and pain.

From the Research

Erysipelas Treatment Overview

• Erysipelas is a severe soft tissue infection usually caused by streptococci, and treatment with antibiotics is essential 2.
• The majority of clinics treat patients with erysipelas as inpatients with intravenous antibiotics, with group G penicillin being the usual first line treatment 2.

First Line Treatment Options

• Group G penicillin (80%) is the most commonly used first line treatment 2.
• Other first line treatment options include amino-penicillins (11%), cephalosporins (16.5%), and anti-staphylococcal penicillins (6.9%) 2.
• Amoxicillin and macrolides are also effective treatment options 3.

Second Line Treatment Options

• Macrolides (63.5%), clindamycin (52.5%), penicillins (18.5%), cephalosporins (40%), and fluoroquinolones (20.5%) are used as second line antibiotics 2.
• Carbapenems, tetracyclines, nitroimidazoles, glycopeptides, aminoglycosides, cotrimoxazole, fusidic acid, and fosfomycin are used rarely 2.

Treatment Duration and Adjuvant Measures

• The median treatment duration is 10 days 2.
• Adjuvant measures include anticoagulation, non-steroidal anti-inflammatory agents, dressings, immobilization, and treatment of local predisposing factors such as interdigital tinea 2.
• Bed rest with the leg elevated is also important, especially for patients with erysipelas of the leg 3.

Specific Treatment Considerations

• Bullous erysipelas represents a severe form of the disease, and Staphylococcus aureus is frequently involved in its complicated course 4.
• The frequency of MRSA isolation suggests that beta-lactam antibiotics may not be sufficient for the treatment of bullous erysipelas anymore, at least in areas with a high incidence of MRSA strains 4.
• A combination therapeutic regimen of amoxicillin + clavulanic acid was found to be linked with the shortest duration of stay in the hospital 5.