What are the treatment options for erysipelas versus cellulitis?

Treatment Options for Erysipelas versus Cellulitis

Both erysipelas and cellulitis should be treated with antibiotics targeting Gram-positive bacteria, particularly streptococci, with erysipelas primarily requiring streptococcal coverage while cellulitis may benefit from additional staphylococcal coverage in specific situations. 1

Distinguishing Features

• Erysipelas:

  • Superficial infection affecting upper dermis and lymphatics
  • Well-demarcated, raised, fiery red borders
  • Primarily caused by beta-hemolytic streptococci (usually Streptococcus pyogenes)
  • S. aureus rarely causes erysipelas

• Cellulitis:

  • Deeper infection affecting dermis and subcutaneous tissue
  • Less defined borders, more diffuse
  • Primarily caused by streptococci
  • S. aureus may be involved, especially with underlying abscess or penetrating trauma

Antibiotic Treatment Options

Oral Therapy (for mild-moderate cases)

Infection	First-line	Alternative Options	Duration
Erysipelas	Penicillin V	Erythromycin, Clindamycin	5-7 days
Cellulitis	Cephalexin, Dicloxacillin	Clindamycin, Amoxicillin-clavulanate	5-7 days

Parenteral Therapy (for severe cases)

Infection	First-line	Alternative Options	Duration
Erysipelas	Penicillin G	Cefazolin, Clindamycin	5-7 days
Cellulitis	Nafcillin, Cefazolin	Clindamycin, Vancomycin (for MRSA)	5-7 days

Treatment Algorithm

1. Assess severity:

   • Mild-moderate: Localized infection without systemic symptoms → Oral antibiotics
   • Severe: Extensive infection, systemic symptoms, immunocompromised → Parenteral antibiotics

2. Select antibiotic based on likely pathogen:

   • Erysipelas: Focus on streptococcal coverage
   • Cellulitis: Cover streptococci and consider S. aureus coverage if:
     • Penetrating trauma
     • Underlying abscess
     • Known MRSA colonization
     • Previous MRSA infection
     • No response to beta-lactam therapy

3. Consider MRSA coverage if:

   • Patient at risk for CA-MRSA
   • No response to first-line therapy within 48-72 hours
   • Known MRSA colonization 1, 2

4. Duration of therapy:

   • Uncomplicated cases: 5 days is as effective as 10 days 1
   • Group G streptococcal infections: Minimum 10 days 2

Adjunctive Measures

1. Elevation of affected area - Important but often neglected aspect of treatment 1

   • Promotes drainage of edema and inflammatory substances
   • Speeds resolution of symptoms

2. Consider corticosteroids in select cases:

   • May hasten resolution in uncomplicated erysipelas
   • Contraindicated in diabetic patients, pregnant women, and those <18 years 1

3. Incision and drainage for any associated abscess 1

4. Treat underlying conditions that may predispose to infection:

   • Tinea pedis
   • Venous eczema
   • Lymphedema
   • Skin trauma/breaks 1, 3

Prevention of Recurrence

For patients with recurrent episodes:

1. Address predisposing factors:

   • Treat interdigital maceration
   • Keep skin well hydrated with emollients
   • Manage underlying edema with compression stockings
   • Elastic compression for venous or lymphatic edema 1, 3

2. Prophylactic antibiotics for frequent recurrences:

   • Monthly intramuscular benzathine penicillin (1.2 MU)
   • OR oral penicillin V (1g twice daily)
   • OR oral erythromycin (250mg twice daily) 1

Common Pitfalls to Avoid

1. Unnecessary MRSA coverage in areas with low MRSA prevalence
2. Failing to elevate the affected limb
3. Not addressing underlying predisposing factors
4. Not performing incision and drainage for abscesses
5. Treating for longer than necessary (5-7 days usually sufficient) 2
6. Inadequate dosing or incorrect antibiotic selection for prophylaxis 4

Monitoring Response

Assess for clinical improvement within 72 hours:

• Decreasing erythema, warmth, and swelling
• Resolution of fever and systemic symptoms
• Improvement in pain

If no improvement after 72 hours, consider:

• Reevaluation of diagnosis
• Drainage procedure if abscess present
• Change in antibiotic therapy 2