What is the recommended treatment for facial erysipelas?

Treatment of Facial Erysipelas

Penicillin is the first-line treatment for facial erysipelas, with recommended dosing of 500 mg orally 3-4 times daily for 7-10 days. 1, 2

Clinical Features and Diagnosis

Facial erysipelas is an acute bacterial infection of the upper dermis and superficial lymphatics characterized by:

• Well-demarcated, fiery red, painful plaque with raised borders
• Rapid onset and progression
• Systemic symptoms including fever, chills, and malaise
• Possible lymphangitis and regional lymphadenopathy
• Clear demarcation from surrounding skin

Diagnosis is primarily clinical, based on the characteristic appearance and associated symptoms. Laboratory tests are generally unhelpful due to low sensitivity of blood cultures (approximately 5%) 3.

Causative Organisms

• Group A Streptococcus (Streptococcus pyogenes) is the predominant cause of facial erysipelas 1
• S. aureus rarely causes true erysipelas but may be involved in some cases 1

Treatment Algorithm

First-Line Therapy:

1. For mild to moderate facial erysipelas in outpatients:

   • Penicillin V 500 mg orally 4 times daily for 7-10 days 2
   • Alternative: Amoxicillin 500 mg orally 3 times daily for 7-10 days 1

2. For severe facial erysipelas requiring hospitalization:

   • Penicillin G intravenously 4
   • Consider hospitalization for:
     • Extensive facial involvement
     • High fever or toxic appearance
     • Inability to take oral medications
     • Immunocompromised status
     • Concern for deeper infection

For Penicillin-Allergic Patients:

• Clindamycin 300 mg orally 3 times daily 1
• Macrolides (e.g., erythromycin 500 mg orally 4 times daily) 1
• Note: Macrolide resistance among group A streptococci has increased in some regions 1

If MRSA is Suspected:

• Consider MRSA coverage only if the patient:
  • Has risk factors for CA-MRSA
  • Does not respond to first-line therapy within 48-72 hours 1
• Options include:
  • Clindamycin (if local resistance rates are low)
  • Trimethoprim-sulfamethoxazole (note: has poor streptococcal coverage)
  • Linezolid for severe cases

Adjunctive Measures

• Elevation of the affected area to reduce edema 1
• Adequate hydration
• Antipyretics for fever
• Consider systemic corticosteroids in selected adult patients without diabetes or immunosuppression to hasten resolution 1
• Treat underlying conditions that may predispose to infection (e.g., tinea, skin trauma) 1

Treatment Duration and Follow-up

• Standard treatment duration is 7-10 days 1
• In uncomplicated cases, 5 days of antibiotic treatment may be as effective as 10 days if clinical improvement occurs 1
• Follow-up within 48-72 hours to assess response to therapy

Prevention of Recurrence

For patients with recurrent episodes of facial erysipelas:

• Address underlying predisposing factors
• Consider prophylactic antibiotics:
  • Monthly intramuscular benzathine penicillin injections (1.2 MU)
  • Or oral therapy with either erythromycin 250 mg twice daily or penicillin V 1 g twice daily 1

Important Caveats

• Facial erysipelas should be treated promptly due to proximity to the central nervous system
• Worsening after initiating therapy may occur due to inflammatory response to bacterial destruction 1
• Slow response may indicate deeper infection, resistant organisms, or underlying conditions
• Repeated episodes can lead to lymphedema and permanent tissue damage 1
• Despite low yield of cultures, penicillin remains the gold standard treatment 5