Recommended Medication for Facial Cellulitis
For typical facial cellulitis, treat with oral beta-lactam monotherapy such as penicillin, amoxicillin, cephalexin, or dicloxacillin for 5 days, as streptococci are the predominant pathogens and MRSA coverage is unnecessary in uncomplicated cases. 1
First-Line Oral Antibiotic Options
The Infectious Diseases Society of America establishes that facial cellulitis (historically termed "erysipelas" when involving the face) requires antibiotic coverage primarily against streptococci 1. Suitable first-line oral agents include:
- Penicillin 1
- Amoxicillin 1
- Cephalexin 1
- Dicloxacillin 1
- Clindamycin (provides both streptococcal and MRSA coverage if needed) 1
Beta-lactam monotherapy achieves 96% success rates even in settings with high MRSA prevalence, confirming that MRSA coverage is typically unnecessary 1, 2.
Treatment Duration
Treat for 5 days if clinical improvement occurs; extend only if symptoms have not improved within this timeframe. 1, 2 Traditional 7-14 day courses are no longer necessary for uncomplicated cases 2.
When to Add MRSA Coverage
MRSA coverage is not routinely needed for typical facial cellulitis 1, 2. However, consider adding MRSA-active therapy if:
- Penetrating trauma is present (especially injection drug use) 1, 2
- Purulent drainage or exudate exists 1, 2
- Concurrent MRSA infection is documented elsewhere 1
- Patient fails beta-lactam therapy 2
MRSA-Active Oral Regimens (if indicated):
- Clindamycin alone (covers both streptococci and MRSA) 1, 2
- Doxycycline 100 mg twice daily PLUS a beta-lactam (doxycycline lacks reliable streptococcal activity) 2, 3
- Trimethoprim-sulfamethoxazole PLUS a beta-lactam (TMP-SMX alone is inadequate for streptococci) 1, 2
Critical caveat: Never use doxycycline or TMP-SMX as monotherapy for typical facial cellulitis, as their activity against beta-hemolytic streptococci is unreliable 1, 2. Two large randomized trials demonstrated that adding TMP-SMX to cephalexin provides no benefit over cephalexin alone in non-purulent cellulitis 4, 5.
Intravenous Therapy Indications
Switch to IV antibiotics for:
- Severe systemic toxicity (fever, hypotension, confusion) 1, 2
- Inability to tolerate oral medications 1
- Rapidly progressive infection 2
IV Antibiotic Options:
- Cefazolin (first-generation cephalosporin) 1
- Nafcillin (penicillinase-resistant penicillin) 1
- Vancomycin 15-20 mg/kg every 8-12 hours (if MRSA coverage needed) 2
For suspected necrotizing fasciitis or severe systemic toxicity, use broad-spectrum combination therapy: vancomycin or linezolid PLUS piperacillin-tazobactam, a carbapenem, or ceftriaxone plus metronidazole 2.
Adjunctive Measures
- Elevate the affected area to promote drainage of edema and inflammatory substances 1, 2
- Treat predisposing conditions including tinea pedis, venous insufficiency, and lymphedema 1, 2
- Consider systemic corticosteroids (prednisone 30-40 mg daily for 7-8 days) in non-diabetic adults to hasten resolution, though evidence is limited 1, 2
Common Pitfalls to Avoid
- Do not reflexively add MRSA coverage simply because community-associated MRSA exists in your area—beta-lactam monotherapy remains highly effective 1, 2, 6
- Do not obtain blood cultures in typical uncomplicated cases; reserve for patients with malignancy, severe systemic features, neutropenia, or severe immunodeficiency 1
- Do not treat beyond 5 days if clinical improvement has occurred—longer courses provide no additional benefit 1, 2
- Avoid monotherapy with doxycycline or TMP-SMX for facial cellulitis, as streptococcal coverage will be inadequate 1, 2