Treatment of Erysipelas

First-Line Treatment

Penicillin V oral 500 mg every 6-8 hours for 5-7 days is the treatment of choice for uncomplicated erysipelas. 1

The FDA-approved dosing for erysipelas specifically recommends penicillin V 125-250 mg every 6-8 hours for 10 days for mild to moderately severe streptococcal infections including erysipelas 2, though more recent guidelines support shorter courses of 5-7 days at higher doses (500 mg) which are equally effective 1
Amoxicillin 500 mg three times daily for 5-7 days is an acceptable alternative oral penicillin option 1
For severe cases requiring hospitalization, intravenous penicillin G should be used 1, 3

Five days of antibiotic treatment is as effective as 10 days for uncomplicated cases showing clinical improvement at day 5. 1

For complicated cases or patients with comorbidities (diabetes, arteritis, cirrhosis, immunodeficiency), complete the full 10-day course 1, 4
Patients treated with penicillin have significantly shorter fever duration (1.7 days) compared to other antibiotics (4.5 days), and shorter overall hospitalization 5, 3

For patients with documented penicillin allergy, use one of the following:

Clindamycin oral 300-450 mg three times daily (or 600 mg IV every 8 hours for severe cases) is the preferred alternative 1, 4
Pristinamycin is another recommended option for penicillin-allergic patients 4
Erythromycin 250 mg four times daily may be used, though resistance in some Streptococcus strains is a concern 1
Avoid vancomycin unless severe penicillin allergy with hospitalized patient (30 mg/kg/day IV in 2 divided doses) 1

Empiric coverage for community-acquired MRSA should be added when:

Patient has risk factors for CA-MRSA 1
No response to first-line streptococcal therapy after 48-72 hours 1
However, this is uncommon as erysipelas is primarily caused by Streptococcus pyogenes, and blood cultures are positive in only 3% of cases 1, 5

Elevation of the affected limb is critical and should be prescribed alongside antibiotics. 1

Bed rest with leg elevation promotes drainage of edema and inflammatory substances 1, 6
Treat the portal of entry: athlete's foot (most common), venous eczema, or trauma 1, 6
Anticoagulation should be considered in patients at risk for venous thromboembolism 6

Recurrence is the most distressing complication and requires aggressive prevention:

Treat all predisposing conditions: athlete's foot, venous eczema, lymphedema 1, 6
Maintain well-hydrated skin with emollients 1
Reduce underlying edema through limb elevation, compression stockings, or pneumatic pressure pumps 1
For recurrent erysipelas (≥2 episodes), prophylactic penicillin is indicated 4
Recognize that subclinical lymphatic dysfunction may be present even in the unaffected limb (79% of patients with impaired drainage in affected limb also have impairment in the contralateral limb), necessitating long-term lymphedema management 7

Hospitalize patients with any of the following:

Routine blood cultures, tissue aspirates, and skin biopsies are NOT recommended for typical erysipelas. 1

Blood cultures have extremely low yield (positive in only 3% of cases) 1, 5
Skin cultures are similarly low yield (positive in 3 of 23 cases in one study) 5
The diagnosis is clinical, based on sudden onset of painful, infiltrated, erythematous plaque with well-defined margins, fever, and regional lymphadenopathy 6, 4

Do not confuse erysipelas with non-bacterial causes of inflammatory edema: contact eczema, acute arthritis, bursitis, chronic venous dermohypodermitis, neutrophilic dermatoses 4
Do not prolong antibiotics beyond necessary duration for uncomplicated cases 1
Do not use broad-spectrum antibiotics when penicillin is appropriate - this increases costs and hospitalization time without improving outcomes 5, 3
Do not neglect lymphatic dysfunction - focus only on infection misses the underlying predisposing factor and increases recurrence risk 7