Is prednisone contraindicated in cellulitis?

Prednisone in Cellulitis: Role and Recommendations

Prednisone is not contraindicated in cellulitis and can be considered as adjunctive therapy in non-diabetic adult patients with uncomplicated cellulitis to hasten resolution of inflammation. 1

Evidence-Based Approach to Corticosteroids in Cellulitis

The 2014 Infectious Diseases Society of America (IDSA) guidelines specifically address the use of systemic corticosteroids in cellulitis:

• Systemic corticosteroids (prednisone 40 mg daily for 7 days) could be considered in non-diabetic adult patients with cellulitis (weak recommendation, moderate-quality evidence) 1
• This recommendation is based on evidence suggesting that corticosteroids can attenuate the inflammatory response and hasten resolution of cellulitis

Patient Selection for Corticosteroid Therapy

Corticosteroids should be considered only in:

• Non-diabetic adults
• Uncomplicated cellulitis (without abscess)
• Patients already receiving appropriate antibiotic therapy
• Patients without severe immunocompromise

Important Exclusions

Avoid corticosteroids in:

• Diabetic patients 1
• Patients with suspected necrotizing infections
• Patients with deep tissue infections
• Patients with severe immunocompromise
• Patients with systemic signs of severe infection (SIRS)

Primary Treatment Algorithm

1. First-line therapy: Appropriate antibiotic coverage is the cornerstone of cellulitis treatment

   • For typical cellulitis: Use antibiotics active against streptococci (most common cause)
   • Duration: 5 days, extending if no improvement 1

2. Consider adjunctive prednisone (40 mg daily for 7 days) in eligible non-diabetic adults 1

3. Additional supportive measures:

   • Elevation of the affected area (strong recommendation) 1
   • Treatment of predisposing factors (edema, underlying skin disorders) 1
   • For lower extremity cellulitis: Examine and treat interdigital toe spaces 1

Evidence Quality and Considerations

The recommendation for corticosteroid use is based on a single randomized, double-blind, placebo-controlled trial where:

• 108 patients with uncomplicated erysipelas received antibiotics plus either:
  • An 8-day tapering course of prednisolone (starting at 30 mg) or
  • Placebo
• Results showed that corticosteroid-treated patients had:
  • Median healing time shortened by 1 day
  • Median treatment time with IV antibiotics shortened by 1 day
  • Median duration of hospital stay shortened by 1 day 1

Potential Pitfalls and Caveats

• Misdiagnosis risk: Ensure the diagnosis is truly cellulitis and not a deeper infection before starting corticosteroids
• Diabetic patients: Corticosteroids may worsen glycemic control and increase infection risk
• Monitoring: Patients on corticosteroids should be monitored for signs of worsening infection
• Limited evidence: The recommendation is based on limited data (weak recommendation)
• Timing: Corticosteroids should only be added after appropriate antibiotic therapy has been initiated

In summary, while prednisone is not contraindicated in cellulitis and may be beneficial in selected patients, it should be used judiciously as an adjunct to appropriate antibiotic therapy in non-diabetic adults with uncomplicated cellulitis.