What is the recommended treatment for toe cellulitis?

Treatment of Toe Cellulitis

For toe cellulitis, a 5-day course of oral antibiotics active against streptococci is the recommended first-line treatment, with extension if the infection has not improved within this period. 1

Antibiotic Selection

• First-line oral antibiotics for uncomplicated toe cellulitis include penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, or cephalexin (500 mg four times daily) 1
• Clindamycin is recommended for patients with penicillin allergies 2, 1
• For severe cases requiring parenteral therapy, appropriate options include:
  • First-generation cephalosporins (cefazolin)
  • Penicillinase-resistant penicillins (nafcillin or oxacillin) 2, 3

Duration of Therapy

• A 5-day course of antibiotics is as effective as a 10-day course for uncomplicated cellulitis if clinical improvement occurs by day 5 4, 1
• Treatment should be extended if the infection has not improved within the initial 5-day period 3, 1

MRSA Considerations

• MRSA coverage is not routinely needed for typical non-purulent toe cellulitis 1
• Consider adding MRSA coverage only in specific situations:
  • Cellulitis associated with penetrating trauma
  • Evidence of MRSA infection elsewhere
  • Purulent drainage
  • History of injection drug use 1
• Options for MRSA coverage include clindamycin alone or combination of SMX-TMP or doxycycline with a β-lactam 1

Adjunctive Measures

• Elevation of the affected toe/foot is important to promote gravity drainage of edema and inflammatory substances 3, 1
• Systemic corticosteroids (such as prednisone 40 mg daily for 7 days) could be considered in non-diabetic patients to reduce inflammation and hasten resolution 4, 1
• Anti-inflammatory agents like ibuprofen (400 mg every 6 hours for 5 days) may help hasten resolution of inflammation when added to antibiotic therapy 5

Addressing Predisposing Factors

• Examine interdigital toe spaces for maceration or fissuring, as streptococci causing lower extremity cellulitis are frequently present in these areas 4
• Treat tinea pedis if present, as it's a common predisposing factor for toe cellulitis 6, 1
• For patients with frequent episodes, consider prophylactic antibiotics such as oral penicillin or erythromycin 3, 1

Hospitalization Criteria

• Consider hospitalization for patients with:
  • Systemic inflammatory response syndrome (SIRS)
  • Altered mental status
  • Hemodynamic instability
  • Concern for deeper or necrotizing infection
  • Poor adherence to therapy
  • Immunocompromise
  • Failure of outpatient treatment 3, 1

Special Considerations for Nail Puncture Wounds

• For toe cellulitis following nail puncture wounds, consider coverage for Pseudomonas aeruginosa, which is commonly isolated in these cases 7
• Ciprofloxacin may be effective for treating infections following nail puncture wounds after appropriate surgical intervention 7

Common Pitfalls to Avoid

• Don't extend treatment unnecessarily beyond 5 days if clinical improvement has occurred 1
• Don't automatically add MRSA coverage for typical non-purulent cellulitis without specific risk factors 1
• Don't overlook the importance of examining interdigital toe spaces, as treating fissuring or maceration may reduce recurrence 4, 1
• Don't miss conditions that can mimic cellulitis, such as venous insufficiency, eczema, deep vein thrombosis, and gout 8