What is the treatment for erysipelas?

Treatment of Erysipelas

Penicillin is the first-line treatment for erysipelas, with oral penicillin V (500 mg four times daily) or amoxicillin (500 mg three times daily) for 7-10 days recommended for uncomplicated cases. 1

Antibiotic Selection

First-line options:

• Oral therapy (for mild to moderate cases):

  • Penicillin V: 500 mg four times daily for 7-10 days 1, 2
  • Amoxicillin: 500 mg three times daily for 7-10 days 1

• Parenteral therapy (for severe cases or those unable to tolerate oral medications):

  • Penicillin G (intravenous) 1
  • First-generation cephalosporin such as cefazolin 1

Alternative options (for penicillin-allergic patients):

• Clindamycin: 300-450 mg orally three times daily 1
• Macrolides (e.g., erythromycin): 500 mg four times daily 1
• Vancomycin (for severe penicillin allergy) 1

Treatment Duration

• 5-7 days is typically sufficient for uncomplicated erysipelas 1
• Studies have shown that 5 days of antibiotic treatment is as effective as a 10-day course for uncomplicated cases 1

Supportive Measures

• Elevation of the affected area to promote gravity drainage of edema and inflammatory substances 1
• Treatment of any underlying conditions that may have predisposed to infection (e.g., tinea pedis, venous eczema, trauma) 1
• Consider systemic corticosteroids as an adjunct for selected adult patients to hasten resolution (contraindicated in diabetic patients, pregnant women, and those under 18 years) 1

Special Considerations

Hospitalization Criteria

Consider inpatient treatment with parenteral antibiotics for patients with:

• Severe systemic symptoms (high fever, significant lymphadenopathy)
• Extensive involvement
• Comorbidities (diabetes, immunocompromised state)
• Inability to tolerate oral medications
• Poor social support

Treatment Response

• Most patients show improvement within 48-72 hours of starting appropriate antibiotics
• If no improvement after 72 hours, consider:
  • Alternative diagnosis
  • Need for drainage if abscess has formed
  • Change in antibiotic therapy

Prevention of Recurrence

Erysipelas has a high recurrence rate, especially in patients with predisposing factors such as lymphedema or venous insufficiency 3, 4. For patients with recurrent episodes:

• Treat underlying conditions (tinea pedis, venous insufficiency, lymphedema)
• Keep skin well hydrated with emollients to prevent cracking
• Reduce underlying edema through:
  • Elevation of extremity
  • Compressive stockings
  • Pneumatic pressure pumps
  • Diuretic therapy if appropriate

Prophylactic Antibiotics

For frequent recurrences despite preventive measures, consider:

• Monthly intramuscular benzathine penicillin injections of 1.2 MU in adults, or
• Oral therapy with twice-daily doses of either 250 mg of erythromycin or 1 g of penicillin V 1, 4

Evidence Quality and Efficacy

• Penicillin remains highly effective against Streptococcus, the primary causative organism of erysipelas 5, 6
• Studies have shown no advantage in using antibiotics other than penicillin for treating erysipelas 5
• Patients treated with penicillin have been shown to have shorter hospitalization periods compared to those treated with other antibiotics 5, 6

Common Pitfalls to Avoid

• Failing to elevate the affected limb
• Not addressing underlying conditions that predispose to infection
• Using unnecessarily broad-spectrum antibiotics when penicillin is effective
• Continuing antibiotics beyond 7 days for uncomplicated infections
• Not considering prophylactic antibiotics in patients with multiple recurrences