What is the treatment for Erysipelas?

Treatment of Erysipelas

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

First-Line Antibiotic Therapy

• Penicillin V oral 500 mg every 6-8 hours remains the gold standard for uncomplicated erysipelas, as this infection is primarily caused by Streptococcus pyogenes. 1
• Amoxicillin 500 mg three times daily for 7-10 days is an acceptable alternative oral penicillin option. 1
• For severe cases requiring hospitalization, intravenous penicillin G should be administered. 2, 3
• Treatment duration of 5-7 days is as effective as 10-day courses for uncomplicated cases showing clinical improvement at day 5. 1

The evidence strongly supports penicillin's efficacy, with retrospective studies demonstrating shorter fever duration (1.7 vs 4.5 days) and shorter hospitalizations compared to other antibiotics, with no difference in treatment failures or recurrences. 4, 5

Alternative Therapy for Penicillin Allergy

For patients with penicillin allergy, clindamycin is the preferred alternative:

• Clindamycin oral 300-450 mg three times daily, or 600 mg IV every 8 hours for severe cases. 1
• Erythromycin 250 mg four times daily may be used, though resistance in some Streptococcus strains is a concern. 1, 6
• Vancomycin IV 30 mg/kg/day in 2 divided doses for severe cases with penicillin allergy. 1

When to Consider Broader Coverage

Empirical coverage for community-acquired MRSA should be considered in specific circumstances:

• Patients with risk factors for CA-MRSA (injection drug use, recent hospitalization, contact sports). 1
• Patients who fail to respond to first-line streptococcal therapy within 48-72 hours. 1
• Presence of purulent drainage or abscess formation (though this would technically not be pure erysipelas). 2

This is a critical distinction: typical erysipelas is a non-purulent infection caused by streptococci and does not require anti-staphylococcal coverage unless specific risk factors are present. 2

Diagnostic Testing

Blood cultures and tissue biopsies are NOT routinely recommended for typical erysipelas:

• Blood cultures are positive in only 3% of cases and rarely change management. 1, 4
• Cultures should be reserved for patients with severe systemic features (hypotension, high fever), malignancy, neutropenia, or severe immunodeficiency. 2
• Skin aspirates or biopsies have similarly low yield (positive in only 3 of 23 cases in one study). 4

Essential Adjunctive Measures

Treatment of the infection site and predisposing factors is crucial to prevent recurrence:

• Elevation of the affected limb to promote drainage of edema and inflammatory substances. 1
• Identification and treatment of entry portals: tinea pedis (athlete's foot), venous eczema, traumatic wounds, or fissures. 1, 7
• Maintaining well-hydrated skin with emollients to prevent skin breakdown. 1
• Compression stockings or pneumatic pressure pumps for patients with chronic lymphedema or venous insufficiency. 1

Prevention of Recurrent Erysipelas

For patients with recurrent episodes (≥2 episodes within 6 months):

• Treat underlying predisposing conditions aggressively, particularly interdigital tinea pedis and chronic venous insufficiency. 1, 7
• Consider prophylactic penicillin (delayed-release penicillin) for patients with frequent recurrences. 7
• Address chronic edema through elevation, compression therapy, and weight management. 1

Common Pitfalls to Avoid

• Do not confuse erysipelas with purulent infections (abscesses, furuncles) that require drainage as primary treatment rather than antibiotics alone. 2
• Avoid unnecessarily broad-spectrum antibiotics (such as anti-MRSA coverage) in typical cases without risk factors, as this contributes to resistance without improving outcomes. 4, 5
• Do not prolong antibiotic treatment beyond 7-10 days for uncomplicated cases showing clinical improvement. 1
• Do not overlook non-infectious mimics such as contact eczema, acute arthritis, bursitis, or inflammatory flare-ups of chronic venous dermohypodermitis, which present similarly but require different management. 7

Inpatient vs Outpatient Management

Most uncomplicated erysipelas can be treated on an outpatient basis with oral antibiotics:

• Hospitalization is indicated for severe systemic features, inability to tolerate oral medications, significant comorbidities (diabetes, cirrhosis, immunodeficiency), or unfavorable social circumstances. 1, 7
• The excellent outcomes with oral therapy and low mortality rate support outpatient management for typical cases. 4