What are the treatment options for potential skin infections such as cellulitis, erysipelas, impetigo, and necrotizing fasciitis, and who should evaluate and treat them?

Treatment Options for Skin Infections and Appropriate Specialists

Skin infections should be treated based on their specific type, with cellulitis and erysipelas managed with appropriate antibiotics by primary care physicians or dermatologists, while necrotizing fasciitis requires immediate surgical consultation and aggressive debridement by surgeons along with infectious disease specialists. 1

Impetigo

• For limited lesions, topical mupirocin is the treatment of choice 2
• For multiple or widespread lesions, oral antibiotics effective against both Staphylococcus aureus and Streptococcus pyogenes should be prescribed 2
• Common oral options include synthetic penicillins, first-generation cephalosporins (cephalexin), macrolides, or clindamycin 2, 3
• Should be evaluated and treated by primary care physicians or dermatologists 4
• Consider MRSA coverage in areas with high prevalence of community-acquired MRSA 2

Erysipelas

• Characterized by fiery red, tender plaques with well-demarcated borders, primarily caused by streptococci 2, 5
• Penicillin is the treatment of choice, administered orally for mild cases or parenterally for more severe presentations 2
• Typically managed by primary care physicians, dermatologists, or infectious disease specialists for complicated cases 2, 1
• Elevation of the affected area is recommended to promote drainage of edema 1

Cellulitis

• Presents as a spreading area of skin inflammation with erythema, warmth, and tenderness 1
• For mild cases without MRSA risk, oral beta-lactams like cephalexin are appropriate 1, 3
• For moderate to severe cases, initial intravenous antibiotics are recommended 1
• In areas with high MRSA prevalence, consider coverage with appropriate agents (trimethoprim-sulfamethoxazole, tetracycline) 2
• Should be treated by primary care physicians, dermatologists, or infectious disease specialists depending on severity 2, 6
• For patients with systemic symptoms, blood cultures should be obtained 1

Necrotizing Fasciitis

• Characterized by severe pain disproportionate to physical findings, wooden-hard feel of subcutaneous tissues, and rapid progression with systemic toxicity 1, 7
• Requires immediate surgical consultation and aggressive debridement, which is the primary therapeutic modality 1, 7
• Empiric broad-spectrum antimicrobial therapy should be initiated immediately 1
• Recommended regimen includes vancomycin, linezolid, or daptomycin, plus one of: piperacillin-tazobactam, carbapenem, ceftriaxone plus metronidazole, or fluoroquinolone plus metronidazole 7, 8
• For necrotizing fasciitis caused by group A streptococci, treatment should include both clindamycin and penicillin 7
• Requires management by a multidisciplinary team including surgeons, infectious disease specialists, and critical care physicians 7, 9
• Surgical debridement should be performed every 24-36 hours until no further debridement is needed 7
• Delay in surgical intervention significantly increases mortality (up to 50% if delayed beyond 24 hours) 7, 9

Specialist Referral Guidelines

• Primary care physicians can manage uncomplicated impetigo, erysipelas, and mild cellulitis 2, 6
• Dermatologists should evaluate cases with atypical presentations or those not responding to initial therapy 1
• Infectious disease specialists should be consulted for complicated infections, immunocompromised patients, or infections requiring complex antimicrobial regimens 2
• Surgical consultation is mandatory for:
  • Suspected necrotizing fasciitis 1, 7
  • Abscesses requiring drainage 2
  • Progressive infections despite appropriate antibiotics 2
  • Deep tissue infections with systemic toxicity 7

Special Considerations

• In immunocompromised patients, consider early dermatology consultation for any skin infection 2
• For patients with neutropenia and skin infections, broad-spectrum antibiotics covering gram-negative bacteria should be initiated promptly 2
• Recurrent cellulitis may require evaluation for underlying conditions (lymphedema, venous insufficiency) and possibly prophylactic antibiotics 2
• Surgical site infections should be evaluated based on depth and severity, with superficial infections treated with antibiotics and deeper infections potentially requiring reoperation 2