What is the initial assessment and treatment for a patient with facial cellulitis?

Assessment of a Patient with Facial Cellulitis

The assessment of facial cellulitis requires prompt identification of causative pathogens (primarily beta-hemolytic streptococci and Staphylococcus aureus) and evaluation for systemic toxicity to guide appropriate antibiotic therapy and determine the need for hospitalization. 1, 2

Clinical Assessment

Key Diagnostic Features

• Acute onset of erythema, warmth, swelling, and tenderness in the facial region
• Well-demarcated borders (especially in erysipelas)
• Pain disproportionate to physical findings (may indicate deeper infection)
• Lymphangitis and regional lymphadenopathy
• Systemic symptoms (fever, chills, malaise)

Severity Assessment

• Mild: Localized infection without systemic signs
• Moderate: More extensive infection with systemic signs (fever, tachycardia)
• Severe: Significant systemic toxicity, hemodynamic instability, altered mental status

Red Flags Requiring Immediate Attention

• Violaceous bullae
• Cutaneous hemorrhage
• Skin sloughing
• Skin anesthesia
• Rapid progression
• Gas in tissue
• Hypotension (systolic BP <90 mmHg)
• Tachycardia (>100 beats/min)
• Fever or hypothermia 1

Laboratory Evaluation

For patients with systemic toxicity, obtain:

• Blood cultures
• Complete blood count with differential (marked left shift suggests severe infection)
• Creatinine, bicarbonate levels
• Creatine phosphokinase (elevated levels 2-3× normal suggest deeper infection)
• C-reactive protein (>13 mg/L suggests severe infection) 1

Differential Diagnosis

Rule out non-infectious mimics:

• Venous stasis dermatitis
• Contact dermatitis
• Deep vein thrombosis
• Panniculitis
• Lymphedema 3, 4

Special Considerations for Facial Cellulitis

• Higher risk of complications due to proximity to central nervous system
• More commonly caused by beta-hemolytic streptococci
• Potential for rapid spread to orbital or intracranial structures
• Lower threshold for hospitalization and IV antibiotics

Treatment Approach

Antibiotic Selection

• First-line (mild cases): Oral antibiotics active against streptococci and MSSA

  • Cephalexin 500mg orally 4 times daily
  • Penicillin
  • Clindamycin 300-450mg orally 3 times daily 1, 2

• For moderate to severe cases: Parenteral therapy

  • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours (if MRSA suspected)
  • Clindamycin IV 600-900mg every 8 hours 2

Treatment Duration

• Standard duration: 5-7 days
• Extend if infection has not improved within this period 1, 2

Hospitalization Criteria

• Presence of SIRS (Systemic Inflammatory Response Syndrome)
• Altered mental status
• Hemodynamic instability
• Concern for deeper or necrotizing infection
• Poor adherence to therapy
• Severe immunocompromise
• Failure of outpatient treatment 1

Prevention of Recurrence

• Identify and treat predisposing conditions:

  • Edema
  • Obesity
  • Eczema
  • Venous insufficiency
  • Local trauma sites 1, 2

• For patients with 3-4 episodes per year despite addressing predisposing factors, consider prophylactic antibiotics:

  • Oral penicillin or erythromycin twice daily for 4-52 weeks
  • Intramuscular benzathine penicillin every 2-4 weeks 1, 2

Common Pitfalls to Avoid

• Misdiagnosing non-infectious mimics as cellulitis, leading to unnecessary antibiotic use
• Failing to recognize signs of deeper infection requiring surgical consultation
• Inadequate coverage for potential pathogens based on risk factors
• Not addressing underlying predisposing factors, leading to recurrence
• Delaying treatment in facial cellulitis, which can lead to rapid spread and complications 4, 5