What is the recommended treatment for Erysipelas (erysipelas)?

Treatment of Erysipelas

Penicillin is the treatment of choice for erysipelas, administered orally for uncomplicated cases or parenterally for severe infections, for 5-10 days. 1

First-Line Treatment Options

• For uncomplicated cases, oral penicillin V 500 mg every 6-8 hours for 5-7 days is recommended as first-line treatment 1, 2
• Amoxicillin 500 mg three times daily for 5-7 days is an effective alternative oral treatment 1
• For more severe cases requiring hospitalization, intravenous penicillin G is recommended, typically 12-24 million units/day divided every 4-6 hours 3
• Treatment duration of 5-7 days is as effective as 10 days for uncomplicated cases if clinical improvement is observed 1

Alternative Treatment Options for Penicillin Allergy

• Clindamycin (300-450 mg orally three times daily or 600 mg IV every 8 hours) is the preferred alternative for patients with severe penicillin allergy 1
• Erythromycin (250 mg four times daily) may be used, though there is risk of resistance in some streptococcal strains 1
• Vancomycin IV (30 mg/kg/day in 2 divided doses) is another effective alternative for severe cases with penicillin allergy 1

Special Considerations

• Empiric therapy for community-acquired MRSA should be considered for patients at risk for CA-MRSA or who do not respond to first-line therapy 4, 1
• Blood cultures have low diagnostic yield (positive in only 3% of cases) and are generally not necessary for typical cases of erysipelas 1, 5
• Erysipelas is primarily caused by streptococci, especially Streptococcus pyogenes, so any second-line antibiotic should have good coverage against these microorganisms 4, 1

Adjunctive Measures

• Elevation of the affected area to promote gravity drainage of edema and inflammatory substances 1
• Treatment of potential entry points such as athlete's foot, eczema, or trauma sites 1
• In uncomplicated cases, systemic corticosteroids may be considered as adjunctive treatment to accelerate symptom resolution 1
• Other helpful adjunctive measures include anticoagulation, non-steroidal anti-inflammatory agents, and appropriate dressings 6

Prevention of Recurrences

• Treating predisposing conditions (athlete's foot, venous eczema, lymphedema) is essential to prevent recurrences 1
• Maintaining well-hydrated skin with emollients helps prevent recurrent infections 1
• Reducing underlying edema through elevation of the limb, compression stockings, or pneumatic pressure pumps 1
• Prophylactic antibiotic therapy with delayed penicillin is recommended for recurrent erysipelas 7

Clinical Pearls and Pitfalls

• Penicillin remains the gold standard treatment with shorter duration of fever after treatment initiation compared to other antibiotics 8
• Avoid confusing erysipelas with other forms of cellulitis or skin infections that may require different treatment approaches 1
• Avoid prolonging antibiotic treatment beyond what is necessary for uncomplicated cases 1
• Studies have shown no advantage in using antibiotics other than penicillin for treating typical erysipelas 5