What is the management for sunburn with secondary cellulitis and blebs on the feet?

Management of Sunburn with Secondary Cellulitis and Blebs on Feet

The management of sunburn with secondary cellulitis and blebs on feet requires prompt antibiotic therapy targeting streptococci, elevation of the affected area, and proper wound care for the blebs. This comprehensive approach addresses both the infectious and inflammatory components of this condition.

Antibiotic Therapy

• For typical cases of cellulitis secondary to sunburn, an antibiotic active against streptococci should be initiated, as streptococci are the most common causative organisms in cellulitis 1
• Suitable oral agents include:
  • Dicloxacillin
  • Cephalexin
  • Clindamycin
  • Erythromycin 1
• For more severe cases with systemic signs of infection (fever, tachycardia, hypotension), parenteral therapy may be indicated with:
  • Nafcillin (penicillinase-resistant penicillin)
  • Cefazolin (first-generation cephalosporin)
  • Clindamycin or vancomycin (for patients with penicillin allergies) 1
• The recommended duration of antibiotic treatment is 5 days, but should be extended if the infection has not improved within this time period 1

Management of Blebs and Wound Care

• For blebs (fluid-filled blisters) on the feet:
  • Small, intact blebs can be left undisturbed 2
  • Larger or painful blebs may require drainage with sterile technique 2
  • After drainage, apply silver sulfadiazine cream to a thickness of approximately 1/16 inch once to twice daily 3
  • Reapply silver sulfadiazine whenever necessary to areas from which it has been removed by patient activity 3
• Continue treatment with silver sulfadiazine cream until satisfactory healing has occurred 3
• Hydrocolloid dressings with silver sulfadiazine may be considered to reduce pain during wound cleansing and promote faster healing 4

Supportive Measures

• Elevation of the affected feet is crucial and often neglected, but essential to promote gravity drainage of edema and inflammatory substances 1
• Systemic corticosteroids (e.g., prednisone 40 mg daily for 7 days) could be considered in non-diabetic adult patients to attenuate inflammation and hasten resolution 1
• Adequate pain control should be provided 4
• Keep the skin well hydrated with emollients to avoid dryness and cracking 1

Prevention of Recurrence

• Address predisposing factors such as:
  • Carefully examine interdigital toe spaces and treat any fissuring, scaling, or maceration 1
  • Treat tinea pedis if present 1
  • Manage any underlying venous insufficiency or lymphedema 1
• For patients with recurrent episodes of cellulitis (3-4 episodes per year), consider prophylactic antibiotics:
  • Oral penicillin V 1g twice daily for 4-52 weeks
  • Erythromycin 250mg twice daily (for penicillin-allergic patients)
  • Monthly intramuscular benzathine penicillin injections of 1.2 MU 1, 5

Indications for Hospitalization

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

Common Pitfalls to Avoid

• Failure to elevate the affected extremity, which can delay resolution 1
• Not addressing underlying conditions like tinea pedis or venous insufficiency 1
• Inadequate duration of antibiotic therapy when improvement is slow 1
• Misdiagnosis of cellulitis, as many conditions can mimic its presentation (venous stasis dermatitis, contact dermatitis, etc.) 6, 7
• Not examining interdigital spaces, which can harbor pathogens and lead to recurrent infections 1