What are the diagnosis and management of Erysipelas (acute bacterial infection of the upper dermis)

From the Guidelines

Erysipelas should be managed with prompt antibiotic therapy, with oral penicillin V (500 mg four times daily for 7-10 days) or amoxicillin (500 mg three times daily for 7-10 days) as the first-line treatment, as recommended by the Infectious Diseases Society of America 1. The diagnosis of erysipelas is typically clinical, based on its characteristic presentation of a well-demarcated, raised, erythematous, warm, and painful skin lesion, typically on the face or lower extremities.

Key Considerations

• The most common causative organism of erysipelas is Group A Streptococcus, and antibiotic therapy should target this organism.
• For penicillin-allergic patients, clindamycin (300-450 mg four times daily) or a macrolide like azithromycin (500 mg on day 1, then 250 mg daily for 4 days) are appropriate alternatives.
• Severe cases with systemic symptoms require intravenous antibiotics, typically penicillin G (2-4 million units every 4-6 hours) or ceftriaxone (1-2 g daily).
• Supportive measures include elevation of the affected limb to reduce edema, adequate hydration, and pain management with acetaminophen or NSAIDs.

Management Strategies

• Patients should rest the affected area and monitor for signs of progression including increasing pain, spreading redness, or systemic symptoms like fever.
• Recurrent erysipelas may require prophylactic antibiotics (penicillin V 250 mg twice daily) and addressing predisposing factors such as tinea pedis, lymphedema, or venous insufficiency.
• Erysipelas must be treated promptly as the infection can spread rapidly through lymphatic vessels, potentially leading to bacteremia or sepsis if left untreated, as highlighted in the guidelines for the diagnosis and management of skin and soft tissue infections 1.

From the FDA Drug Label

Streptococcal Infections (without bacteremia) Mild-to-moderate infections of the upper respiratory tract, scarlet fever, and mild erysipelas. NOTE: Streptococci in groups A, C, G, H, L, and M are very sensitive to penicillin.

• Diagnosis: The FDA drug label does not provide information on the diagnosis of erysipelas.
• Management: Penicillin V is indicated for the treatment of mild erysipelas caused by penicillin G-sensitive microorganisms, specifically streptococci in groups A, C, G, H, L, and M 2.

From the Research

Diagnosis of Erysipelas

• Erysipelas is an acute bacterial infection of the dermis and hypodermis that is associated with clinical inflammation 3
• The diagnosis of erysipelas can be based on careful examination for local signs and symptoms, such as pain, erythema, and swelling, together with elevated erythrocyte sedimentation rate (ESR) 4
• Patients typically have a well-demarcated, erythematous, indurated, rapidly spreading patch with a palpable advancing border on the face or extremities 5
• The diagnosis is made clinically by the spreading erythema and overheating of the skin, the reduced general condition with fever and chills, as well as by means of serological inflammation parameters 6

Management of Erysipelas

• Treatment of patients with erysipelas has been evaluated in a small number of studies, with penicillin G, amoxicillin, and macrolides being effective options 3
• Penicillin seems to preserve its fundamental role in the treatment of disease 4
• Systemic therapy is carried out with penicillin usually, and long-term therapy of the lymphoedema and the consistent avoidance and treatment of entry sites are essential, especially for the prevention of recurrence 6
• A combination therapeutic regimen of amoxicillin + clavulanic acid was the most commonly used treatment option and was linked with the shortest duration of stay in the hospital 7

Complications and Prevention

• Potential complications include abscess formation, necrotizing fasciitis, septicemia, recurrent infection, and lymphedema 5
• Recurrence is a common complication, and long-term antibacterial therapy is required for patients with recurrence 3
• The portal of entry will also require treatment, and bed rest with the leg elevated is also important 3
• Anticoagulants are indicated in patients at risk of venous thromboembolism 3