What is the treatment for Erysipelas?

Treatment of Erysipelas

For typical erysipelas, treat with oral penicillin V 500 mg every 6-8 hours or amoxicillin 500 mg three times daily for 5-10 days, as this provides excellent streptococcal coverage and remains the gold standard therapy. 1, 2

First-Line Antibiotic Therapy

Oral treatment options for uncomplicated cases:

• Penicillin V 500 mg every 6-8 hours for 5-10 days is the treatment of choice, as erysipelas is primarily caused by Streptococcus pyogenes and remains highly penicillin-sensitive 1, 2, 3
• Amoxicillin 500 mg three times daily for 5-10 days is an equally effective alternative with similar streptococcal coverage 1, 2
• Other acceptable oral options include cephalexin, dicloxacillin, or amoxicillin-clavulanate for typical cases 1

Treatment duration:

• 5-7 days of antibiotics is as effective as 10 days for uncomplicated cases showing clinical improvement at day 5 2
• Complete 10 days of treatment for complicated cases or patients with significant comorbidities (diabetes, arteritis, cirrhosis, immunodeficiency) 2, 4

Penicillin Allergy Alternatives

For patients with penicillin allergy:

• Clindamycin 300-450 mg orally three times daily is the preferred alternative for severe penicillin allergy 2
• Erythromycin 250 mg four times daily may be used, though resistance in some streptococcal strains is a concern 2, 5
• Pristinamycin is another option in penicillin-allergic patients 4

Severe Cases Requiring Hospitalization

Indications for hospitalization and IV therapy include: 1, 4

• High fever with hypotension or confusion
• Severe systemic toxicity
• Concern for deeper or necrotizing infection
• Significant comorbidities (malignancy, neutropenia, severe immunodeficiency)
• Poor adherence to therapy or unfavorable social context

IV treatment options for severe cases:

• Clindamycin 600 mg IV every 8 hours for severe penicillin allergy 2
• Vancomycin 30 mg/kg/day IV in 2 divided doses for severe cases with penicillin allergy 2

Essential Supportive Measures

Non-antibiotic interventions are critical for optimal outcomes:

• Elevation of the affected limb to promote drainage of edema and inflammatory substances 2
• Bed rest during acute phase 3
• Anticoagulation prophylaxis for patients at risk of venous thromboembolism 3
• Treatment of the portal of entry (athlete's foot, eczema, skin trauma, fissured toe webs) to prevent recurrence 2, 3

Diagnostic Considerations

Routine testing is generally unnecessary:

• Blood cultures, tissue aspirates, and skin biopsies are not needed for typical cases as they have extremely low yield (positive in only 3% of cases) 1, 2, 6
• Consider blood cultures only for patients with malignancy, severe systemic features (high fever, hypotension), or unusual predisposing factors (immersion injury, animal bites, neutropenia) 1

Prevention of Recurrence

Recurrence is the most common complication and requires aggressive prevention strategies:

• Treat predisposing conditions: athlete's foot (tinea pedis), venous eczema, lymphedema, chronic venous insufficiency 2, 3, 4
• Maintain well-hydrated skin with regular emollient use 2
• Reduce underlying edema through limb elevation, compression stockings, or pneumatic pressure pumps 2
• Long-term antibiotic prophylaxis with delayed-release penicillin is recommended for patients with recurrent erysipelas 4, 7

Critical Pitfalls to Avoid

Common errors in erysipelas management:

• Do not empirically cover for MRSA in typical cases, as erysipelas is primarily streptococcal; MRSA coverage should only be considered in patients with risk factors for community-acquired MRSA or those failing first-line therapy 2
• Do not confuse erysipelas with purulent collections (abscesses, furuncles), which require drainage rather than antibiotics alone 1
• Do not prolong antibiotics beyond necessary duration in uncomplicated cases responding well at 5 days 2
• Recognize bullous erysipelas as a severe form that may involve Staphylococcus aureus (including MRSA in some regions) and may require broader coverage 8

Special Populations

Facial erysipelas:

• Treat with the same antibiotic regimens as lower extremity disease 1, 3
• Consider hospitalization more readily due to proximity to critical structures

Pregnant patients:

• Penicillin and amoxicillin remain safe and effective choices 5
• Avoid fluoroquinolones and tetracyclines