What is the recommended treatment for mild superficial soft tissue thickening in the region of the vulva with subcutaneous stranding in the mons pubis, suggestive of cellulitis?

Treatment for Vulvar Cellulitis with Subcutaneous Stranding

For mild superficial soft tissue thickening in the region of the vulva with subcutaneous stranding in the mons pubis suggestive of cellulitis, treatment should begin promptly with antibiotics effective against typical gram-positive pathogens, especially streptococci. 1

Antibiotic Selection

• For mild, early cellulitis without significant comorbidities, oral beta-lactams (such as penicillin, amoxicillin, dicloxacillin, or cephalexin) are appropriate first-line therapy in areas where CA-MRSA is not prevalent 1
• A 5-day course of antimicrobial therapy is as effective as a 10-day course if clinical improvement occurs by day 5 1
• If MRSA is suspected based on risk factors (recent hospitalization, previous MRSA infection, injection drug use), consider alternative antibiotics such as clindamycin, trimethoprim-sulfamethoxazole, or doxycycline 1
• Clindamycin is specifically indicated for serious skin and soft tissue infections caused by susceptible strains of streptococci and staphylococci 2

Assessment and Monitoring

• Blood cultures are not routinely recommended for typical cases of cellulitis but should be considered in patients with malignancy, neutropenia, severe immunodeficiency, or systemic signs of infection 1
• Monitor for signs of deeper infection or abscess formation, which would require different management approaches 1
• Assess for systemic signs of infection such as fever, tachycardia, confusion, hypotension, or leukocytosis, which may necessitate parenteral therapy 1

Special Considerations for Vulvar Cellulitis

• Vulvar cellulitis may have different microbial etiology than cellulitis in other locations, potentially including enteric flora, especially in proximity to the groin 1
• If there is evidence of abscess formation, incision and drainage should be performed 1
• For vulvar region infections with significant cellulitis surrounding an abscess, antibiotic therapy should be administered in addition to drainage 1

Additional Measures

• Elevation of the affected area is important to promote gravity drainage of edema and inflammatory substances 1
• Address any underlying conditions that may predispose to infection, such as diabetes, chronic edema, or local skin conditions 1, 3
• Keep the skin well hydrated with emollients to avoid dryness and cracking 1

When to Consider Hospitalization

• Hospitalization should be considered for patients with SIRS (systemic inflammatory response syndrome), altered mental status, hemodynamic instability, or if there is concern for deeper or necrotizing infection 1
• Immunocompromised patients or those with poor adherence to therapy may also require inpatient treatment 1

Prevention of Recurrence

• For recurrent cellulitis, search for and treat local causes such as chronic skin conditions 1
• Consider prophylactic antibiotics for patients with frequent recurrences despite management of underlying conditions 1, 3
• Options include monthly intramuscular benzathine penicillin injections or daily oral antibiotics such as penicillin V or erythromycin 1

Pitfalls to Avoid

• Do not mistake cellulitis for necrotizing soft tissue infection, which requires immediate surgical intervention. Warning signs include rapid progression, severe pain, crepitus, skin discoloration, and systemic toxicity 1, 4
• Avoid treating simple abscesses with antibiotics alone without drainage 1
• Do not continue ineffective antibiotics; reassess if no improvement is seen within 48-72 hours 1, 5