What is the treatment for cellulitis of the toe?

Treatment of Cellulitis of the Toe

For typical cases of cellulitis of the toe without systemic signs of infection, an antimicrobial agent active against streptococci such as penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, or cephalexin is recommended for a 5-day course. 1

Antibiotic Selection Based on Severity

Mild Cellulitis (No Systemic Signs)

• First-line treatment: Oral antibiotics active against streptococci such as penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, or cephalexin (500 mg four times daily) 1, 2
• Alternative: Clindamycin 300-450 mg orally every 6 hours for patients with penicillin allergy 1, 3
• Duration: 5 days, extending if infection has not improved within this period 1

Moderate to Severe Cellulitis (With Systemic Signs)

• Consider coverage against both streptococci and methicillin-susceptible S. aureus (MSSA) 1
• For patients with SIRS, penetrating trauma, evidence of MRSA elsewhere, or injection drug use, consider vancomycin or another antimicrobial effective against both MRSA and streptococci 1, 4
• For severely compromised patients, broad-spectrum coverage with vancomycin plus either piperacillin-tazobactam or imipenem/meropenem may be considered 1

Adjunctive Measures

• Elevation of the affected toe/foot to promote gravity drainage of edema 1
• Carefully examine interdigital toe spaces and treat any fissuring, scaling, or maceration to eradicate colonization with pathogens 1
• Identify and treat predisposing conditions such as tinea pedis, edema, obesity, eczema, or venous insufficiency 1, 2
• Systemic corticosteroids (e.g., prednisone 40 mg daily for 7 days) could be considered in non-diabetic adult patients to reduce inflammation and hasten resolution 1, 2

Hospitalization Criteria

• Consider inpatient treatment if there is:
  • Systemic inflammatory response syndrome (SIRS) 1, 2
  • Altered mental status or hemodynamic instability 1
  • Concern for deeper or necrotizing infection 1
  • Poor adherence to therapy 1
  • Severe immunocompromise 1
  • Failure of outpatient treatment 1, 2

Prevention of Recurrence

• For patients with 3-4 episodes of cellulitis per year despite treatment of predisposing factors, consider prophylactic antibiotics 1
• Options include oral penicillin or erythromycin twice daily for 4-52 weeks, or intramuscular benzathine penicillin every 2-4 weeks 1
• Continue prophylaxis as long as predisposing factors persist 1

Common Pitfalls to Avoid

• Don't routinely obtain cultures of blood or cutaneous aspirates in typical cases 1
• Don't automatically add MRSA coverage for typical non-purulent cellulitis without specific risk factors 1, 2
• Don't extend treatment unnecessarily beyond 5 days if clinical improvement has occurred 1, 2
• Don't forget to examine interdigital toe spaces in lower-extremity cellulitis 1, 2
• Don't overlook the importance of treating underlying conditions that predispose to cellulitis, such as tinea pedis 1, 5

Special Considerations

• In areas with high prevalence of community-associated MRSA, antibiotics with activity against MRSA (such as trimethoprim-sulfamethoxazole or clindamycin) may be preferred for empiric therapy 6
• For β-hemolytic streptococcal infections, treatment should continue for at least 10 days 1, 3
• Consider adding an anti-inflammatory agent to hasten resolution of inflammation 7