What is the treatment for contact dermatitis with cellulitis?

Treatment of Contact Dermatitis with Cellulitis

For contact dermatitis complicated by cellulitis, the recommended treatment is a 5-day course of an antibiotic active against streptococci (such as penicillin, amoxicillin, dicloxacillin, or cephalexin) combined with topical steroids for the dermatitis component. 1, 2

Antibiotic Selection

• For non-purulent cellulitis complicating contact dermatitis, select antibiotics active against streptococci, which are the most common causative organisms 2
• First-line oral options include:
  • Penicillin or amoxicillin
  • Dicloxacillin
  • Cephalexin (500 mg four times daily)
  • Clindamycin (for penicillin-allergic patients) 1, 2
• MRSA coverage is generally not needed for typical non-purulent cellulitis unless specific risk factors are present 1, 3
• Consider MRSA coverage only if cellulitis is associated with:
  • Penetrating trauma
  • Evidence of MRSA infection elsewhere
  • Purulent drainage
  • Systemic inflammatory response syndrome (SIRS)
  • Injection drug use 1, 2

Duration of Treatment

• A 5-day course of antimicrobial therapy is as effective as a 10-day course for uncomplicated cellulitis if clinical improvement occurs by day 5 1, 2
• Extend treatment only if the infection has not improved within the initial 5-day period 1, 2

Management of Contact Dermatitis Component

• For allergic contact dermatitis:
  • Apply topical steroids to mitigate flares of dermatitis 1
  • For extensive involvement, consider systemic steroids (e.g., prednisone 40 mg daily for 7 days) in non-diabetic patients 1, 2
  • Identify and avoid allergens 1
  • Consider patch testing for recalcitrant cases 1
• For irritant contact dermatitis:
  • Identify and avoid irritants 1
  • Apply moisturizers to restore skin barrier 1
  • Consider topical steroids if conservative measures fail 1

Adjunctive Measures

• Elevate the affected area to promote gravity drainage of edema and inflammatory substances 1, 2
• Apply moisturizer after washing hands and before wearing gloves if hands are affected 1
• For severe cases, consider the "soak and smear" technique: soak the affected area in plain water for 20 minutes and immediately apply moisturizer to damp skin nightly for up to 2 weeks 1
• Treat predisposing factors such as edema, underlying skin conditions, or tinea pedis 1

Hospitalization Criteria

• Most patients can be treated as outpatients 1, 2
• Consider hospitalization if the patient has:
  • Systemic inflammatory response syndrome (SIRS)
  • Altered mental status
  • Hemodynamic instability
  • Concern for deeper or necrotizing infection
  • Poor adherence to therapy
  • Severe immunocompromise
  • Failure of outpatient treatment 1, 2

Prevention of Recurrence

• Identify and treat predisposing conditions 1
• For patients with frequent recurrences (3-4 episodes per year), consider prophylactic antibiotics 1
• For contact dermatitis prevention:
  • Maintain skin barrier with regular moisturizing 1
  • Avoid known allergens and irritants 1
  • Use barrier creams when appropriate 1

Common Pitfalls to Avoid

• Don't extend antibiotic treatment unnecessarily beyond 5 days if clinical improvement has occurred 1, 2
• Don't automatically add MRSA coverage for typical non-purulent cellulitis without specific risk factors 1, 2, 4
• Don't neglect the underlying contact dermatitis component, which requires specific management beyond antibiotics 1, 5
• Don't miss conditions that mimic cellulitis, such as venous stasis dermatitis, contact dermatitis alone, or deep vein thrombosis 6, 7