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 Infectious Diseases Society of America establishes penicillin as the definitive first-line agent, with oral administration preferred for uncomplicated cases 1
The FDA-approved dosing for erysipelas specifically is 125-250 mg every 6-8 hours for 10 days, though contemporary guidelines support shorter courses 2
For uncomplicated cases with clinical improvement at 5 days, a 5-7 day course is as effective as 10 days, reducing unnecessary antibiotic exposure 1
Oral penicillin is equally effective as intravenous therapy for uncomplicated cases, with no difference in fever duration, hospital stay, or recurrence rates 3

For patients with penicillin allergy, clindamycin is the preferred alternative. 1

Clindamycin dosing: 300-450 mg orally three times daily or 600 mg IV every 8 hours for severe cases 1
Erythromycin 250 mg four times daily is another option, though resistance in Streptococcus strains is a concern 1
Vancomycin 30 mg/kg/day IV in 2 divided doses is reserved for severe cases with penicillin allergy 1

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

Erysipelas is primarily caused by Streptococcus pyogenes, making anti-streptococcal coverage the priority 1, 4
MRSA coverage is not routinely needed for typical erysipelas 1
Blood cultures have extremely low yield (positive in only 3% of cases) and are not recommended for typical presentations 1, 5

Elevation of the affected limb and treatment of the portal of entry are critical components of management. 1

Bed rest with leg elevation promotes drainage of edema and inflammatory mediators 1, 4
Identify and treat predisposing conditions: athlete's foot (most common portal of entry), venous eczema, trauma, or lymphedema 1, 4
Anticoagulation should be considered in patients at risk for venous thromboembolism 4

Addressing underlying lymphatic dysfunction and entry points is essential to prevent recurrent episodes. 1

Treat athlete's foot, venous eczema, or other skin breakdown aggressively 1
Maintain well-hydrated skin with emollients 1
Reduce underlying edema through limb elevation, compression stockings, or pneumatic pressure pumps 1
Subclinical lymphatic impairment is present in 79% of patients with erysipelas, even in the unaffected limb, making lymphedema management crucial 6
Long-term prophylactic antibiotics (penicillin) may be necessary for patients with recurrent erysipelas 7

Outpatient oral therapy is appropriate for most cases; hospitalize only for severe disease or significant comorbidities. 1, 7

Indications for hospitalization include: severe local or systemic signs, diabetes, arterial insufficiency, cirrhosis, immunodeficiency, or unfavorable social context 7
Most patients can be treated empirically on an outpatient basis without laboratory workup 5

Do not prolong antibiotics beyond 5-7 days for uncomplicated cases responding to therapy 1
Do not routinely order blood cultures, tissue aspirates, or skin biopsies for typical presentations 1
Do not use broad-spectrum antibiotics covering MRSA empirically without risk factors 1
Do not neglect to identify and treat the portal of entry, as this is the most important factor in preventing recurrence 1, 4