What is the treatment for Erysipelas?

Treatment of Erysipelas

First-Line Treatment

Penicillin is the treatment of choice for erysipelas, administered as penicillin V 500 mg orally every 6-8 hours for 5-10 days in uncomplicated cases. 1

• Amoxicillin 500 mg three times daily for 5-10 days is an equally effective alternative oral penicillin option. 1
• For severe cases requiring hospitalization, intravenous penicillin G should be administered at doses of 12-24 million units/day divided every 4-6 hours depending on severity. 2
• The causative organism is predominantly beta-hemolytic Streptococcus pyogenes (group A streptococcus), which remains highly susceptible to penicillin. 1, 3

Treatment Duration

For uncomplicated cases showing clinical improvement at 5 days, a 5-7 day course is as effective as 10 days of treatment. 1

• Patients with comorbidities (diabetes, arteritis, cirrhosis, immunodeficiency) or complicated cases should complete the full 10-day course. 1
• Treatment should continue for at least 48-72 hours after the patient becomes asymptomatic. 2

Penicillin Allergy Alternatives

For patients with documented penicillin allergy, the following alternatives are recommended:

• Clindamycin oral (300-450 mg three times daily) or IV (600 mg every 8 hours) is the preferred alternative for severe penicillin allergy. 1
• Erythromycin oral 250 mg four times daily may be used, though resistance in some Streptococcus strains is a concern. 1
• Vancomycin IV (30 mg/kg/day in 2 divided doses) is reserved for severe cases with penicillin allergy requiring parenteral therapy. 1

Essential Adjunctive Measures

Elevation of the affected limb is critical to promote gravity drainage of edema and inflammatory substances. 1

• Bed rest with leg elevation should be implemented alongside antibiotic therapy. 4
• Anticoagulants are indicated for patients at risk of venous thromboembolism during the acute phase. 4

Treatment of Entry Points and Predisposing Factors

Identifying and treating the portal of entry is essential to prevent recurrence, which is the most common complication. 1, 4

• Treat athlete's foot (tinea pedis) with antifungal therapy, as this is the most common entry point. 1, 3
• Address venous eczema, chronic edema, and skin fissures with appropriate dermatologic management. 1, 3
• Maintain well-hydrated skin with emollients to prevent skin barrier breakdown. 1
• Reduce underlying edema through compression stockings or pneumatic pressure pumps for patients with lymphedema or venous insufficiency. 1

Special Considerations for MRSA Coverage

Empiric coverage for community-acquired MRSA should be considered only in patients with specific risk factors or those failing first-line therapy. 1

• Erysipelas is primarily streptococcal; routine MRSA coverage is not indicated for typical presentations. 1, 3
• Risk factors warranting MRSA coverage include: previous MRSA infection, injection drug use, or lack of response to beta-lactam therapy after 48-72 hours. 1

Hospitalization Criteria

Hospitalization is warranted when any of the following are present:

• Severe systemic symptoms (high fever, hypotension, altered mental status). 5
• Significant comorbidities (diabetes, arteritis, cirrhosis, immunodeficiency). 1, 5
• Inability to tolerate oral medications. 5
• Unfavorable social context preventing adequate outpatient management. 5
• Concern for necrotizing fasciitis or other severe complications. 4

Prevention of Recurrence

For patients with recurrent erysipelas (≥2 episodes):

• Long-term prophylactic antibiotic therapy with benzathine penicillin G intramuscularly or oral penicillin V is recommended. 4, 5
• Aggressive treatment of predisposing conditions (athlete's foot, venous insufficiency, lymphedema) is essential. 1, 3
• Maintain skin integrity through regular emollient use and prompt treatment of minor skin trauma. 1

Common Pitfalls to Avoid

• Do not confuse erysipelas with other forms of cellulitis requiring broader antibiotic coverage—erysipelas is streptococcal and penicillin-sensitive. 1
• Avoid routine blood cultures in typical cases, as they are positive in only 3% of cases and rarely change management. 1
• Do not prolong antibiotic treatment beyond what is necessary for uncomplicated cases showing clinical improvement. 1
• Do not overlook the portal of entry—failure to treat predisposing conditions leads to high recurrence rates. 1, 4