What is the recommended treatment for cellulitis of the back with peeling skin?

Treatment of Cellulitis of the Back with Peeling Skin

For cellulitis of the back with peeling skin, the recommended treatment is a 5-day course of oral antibiotics active against streptococci (such as penicillin, amoxicillin, dicloxacillin, cephalexin, or clindamycin), with extension if clinical improvement has not occurred by day 5. 1, 2

Antibiotic Selection

• First-line treatment should include antibiotics active against streptococci, as they are the most common causative organisms in non-purulent cellulitis 3, 1
• Appropriate oral antibiotic options include:
  • Penicillin 1, 2
  • Amoxicillin 1, 2
  • Amoxicillin-clavulanate 1, 2
  • Dicloxacillin 1, 2
  • Cephalexin (500 mg four times daily) 1, 2
  • Clindamycin (300-450 mg three times daily) 1, 2

Duration of Therapy

• A 5-day course of antimicrobial therapy is as effective as a 10-day course for uncomplicated cellulitis if clinical improvement has occurred by day 5 3, 4
• Treatment should be extended if the infection has not improved within the initial 5-day period 1, 2
• Evaluate response to therapy every 2-5 days initially, looking for resolution of local symptoms and clinical signs of inflammation 5

MRSA Considerations

• MRSA is an unusual cause of typical cellulitis and treatment for this organism is usually unnecessary 3
• Consider MRSA coverage only in specific situations:
  • Cellulitis associated with penetrating trauma 3, 2
  • Evidence of MRSA infection elsewhere 3, 2
  • Purulent drainage 3, 2
  • History of injection drug use 1, 2
• If MRSA coverage is needed, options include:
  • Clindamycin alone 2
  • Trimethoprim-sulfamethoxazole (with a β-lactam for streptococcal coverage) 2
  • Doxycycline (with a β-lactam for streptococcal coverage) 2

Adjunctive Measures

• Elevation of the affected area to promote drainage of edema and inflammatory substances 1, 2
• For peeling skin, gentle wound care with:
  • Regular cleansing with mild soap and water 6
  • Keeping the area clean and dry 6
  • Avoiding harsh scrubbing that could damage fragile skin 6
• Consider systemic corticosteroids, such as prednisone 40 mg daily for 7 days, in non-diabetic patients to reduce inflammation and hasten resolution 1
• Non-steroidal anti-inflammatory drugs (NSAIDs) may help hasten resolution of inflammation when used alongside antibiotics 7

Hospitalization Criteria

Consider hospitalization if the patient presents with:

• Severe infection with systemic inflammatory response syndrome 1, 2
• Altered mental status 1, 2
• Hemodynamic instability 1, 2
• Concern for deeper or necrotizing infection 1, 2
• Poor adherence to therapy 1, 2
• Immunocompromised state 1, 2
• Failure of outpatient treatment 1, 2

Prevention of Recurrence

• Identify and treat predisposing conditions 1, 8
• For patients with frequent episodes (3-4 per year), consider prophylactic antibiotics such as:
  • Oral penicillin 1, 2
  • Erythromycin 1, 2
  • Intramuscular benzathine penicillin 1, 2

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, 6
• Don't overlook the importance of elevating the affected area to reduce edema 1, 2
• Don't fail to recognize when cellulitis is not improving, which may indicate a need for broader antibiotic coverage or consideration of alternative diagnoses 6
• Don't forget to address the peeling skin with appropriate wound care to prevent secondary infection 6