From the Guidelines
The best approach for managing chronic recurrent cellulitis associated with chronic lymphedema involves a comprehensive strategy combining preventive antibiotics, meticulous skin care, and lymphedema management. For patients with frequent episodes (typically 2-3 or more per year), prophylactic antibiotics are recommended, with penicillin V 250-500mg twice daily or erythromycin 250mg twice daily for those with penicillin allergy, as supported by the Infectious Diseases Society of America guidelines 1. This prophylactic regimen should continue for 1-2 years, after which reassessment for continuation is needed. Daily skin care is essential, including gentle cleansing, moisturizing, and prompt treatment of any cuts, cracks, or fungal infections. Compression therapy forms the cornerstone of lymphedema management, using properly fitted compression garments during the day and multi-layer bandaging or compression devices at night, as recommended by the guidelines 1. Regular limb elevation, weight management, and physical activity that incorporates decongestive exercises help reduce fluid accumulation. For acute cellulitis episodes, prompt treatment with antibiotics like flucloxacillin 500mg four times daily for 7-14 days is necessary, as suggested by the guidelines 1. This comprehensive approach addresses both the infectious component through antibiotics and the underlying lymphatic dysfunction through physical measures, effectively reducing the frequency and severity of cellulitis episodes while improving quality of life. Key considerations include:
- Identifying and treating predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities 1
- Administering prophylactic antibiotics for patients with frequent episodes of cellulitis, despite attempts to treat or control predisposing factors 1
- Using compression therapy and other physical measures to manage lymphedema and reduce fluid accumulation 1
- Providing prompt treatment for acute cellulitis episodes with antibiotics and supportive care 1
From the Research
Management of Chronic Recurrent Cellulitis
Overview of Treatment Approaches
The management of chronic recurrent cellulitis associated with chronic lymphedema involves a combination of physical therapy, drug therapy, and surgery. The primary objectives of treatment are to reduce swelling, restore shape, and prevent inflammatory episodes, such as recurrent cellulitis 2.
Physical Therapy
Physical therapy aims to reduce excessive capillary filtration and improve drainage of interstitial fluid and macromolecules from congested regions to normally draining lymph node sites. This can be achieved through a combination of:
- Compression
- Exercise
- Massage, if possible
Drug Therapy
Drug therapy comprises:
- Diuretics, which may be used in edema of mixed origin and in palliative (cancer) circumstances, although their use in pure lymphedema is physiologically unsound 2
- Coumarin/flavonoids, which have been shown to reduce swelling in all types of lymphedema 2
- Antibiotics, which are essential in the management of cellulitis, a common complication of chronic oedema 3
- Penicillin V, which is the preferred antibiotic for prevention of recurrent cellulitis, although other antibiotics and new drugs can be considered in cases of β-lactam allergy, intolerance, or failure 4
Surgical Treatment
Surgery is indicated at an early stage for facial swelling, where vision is compromised, or genital lymphedema, where genitourinary function is affected. Otherwise, reducing operations should only be performed when alternative therapy has failed 2. Lymphaticovenous anastomosis (LVA) can reduce the frequency of cellulitis in patients with lymphedema, and the combination of surgical treatment and conservative treatment is important for severe lymphedema treatment 5, 6.
Prevention of Recurrent Cellulitis
Prevention of recurrent cellulitis involves:
- Management of underlying predisposing conditions
- Evaluation of pharmacological measures
- Targeting risk factors, if present, in association with antibiotic prophylaxis 4
- LVA, which has been shown to reduce the rate of cellulitis in patients with lymphoedema 6
Key considerations in the management of chronic recurrent cellulitis associated with chronic lymphedema include:
- A rigorous approach to the management of risk factors and treatment of acute infection
- The use of specialized and multidisciplinary skills
- The importance of preventing recurrence, as the risk of recurrence rises with repeated episodes 4