What is the recommended treatment for erysipelas?

Treatment for Erysipelas

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

First-Line Antibiotic Treatment

For uncomplicated cases:

• Penicillin V oral 500 mg every 6-8 hours is the treatment of choice 1
• Treatment duration of 5-7 days is as effective as 10 days if clinical improvement is seen 1
• Amoxicillin 500 mg three times daily for 5-7 days is an acceptable alternative 1
• The FDA-approved dosing for erysipelas is 125-250 mg every 6-8 hours for 10 days, though shorter courses are now supported by guidelines 2

For severe or complicated cases:

• Complete 10 days of antibiotic treatment 1
• Consider intravenous penicillin initially, then transition to oral therapy 1
• Patients with comorbidities (diabetes, arteritis, cirrhosis, immunodeficiency) or signs of severity require hospitalization and parenteral therapy 3

Penicillin Allergy Alternatives

For patients with penicillin allergy:

• Clindamycin oral or IV (300-450 mg three times daily orally or 600 mg every 8 hours IV) is the preferred alternative 1
• Erythromycin oral 250 mg four times daily, though resistance in Streptococcus strains is a concern 1
• Vancomycin IV (30 mg/kg/day in 2 divided doses) for severe cases with penicillin allergy 1
• Pristinamycin is recommended in some European guidelines for penicillin-allergic patients 3

Critical Adjunctive Measures

Essential supportive care includes:

• Elevation of the affected limb to promote drainage of edema 1
• Treatment of the entry point (athlete's foot, eczema, trauma, interdigital tinea) 1
• Maintaining well-hydrated skin with emollients 1
• Reducing underlying edema through compression stockings or pneumatic pressure pumps 1

When to Consider MRSA Coverage

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

• Patient has risk factors for CA-MRSA 1
• Patient fails to respond to first-line streptococcal therapy 1
• However, erysipelas is primarily caused by Streptococcus pyogenes, so routine MRSA coverage is not necessary for typical cases 1

Common Pitfalls to Avoid

Do not routinely order blood cultures, tissue aspirates, or skin biopsies - blood cultures are positive in only 3% of cases and have minimal impact on management 1, 4

Do not prolong antibiotic treatment beyond what is necessary - uncomplicated cases respond well to 5-7 days of therapy 1

Do not confuse erysipelas with other conditions requiring different treatment, such as contact eczema, acute arthritis, bursitis, or chronic venous dermohypodermitis 3

Do not use broad-spectrum antibiotics for uncomplicated erysipelas - reserve these for truly complicated skin and soft tissue infections with polymicrobial involvement 5

Prevention of Recurrence

For patients with recurrent erysipelas:

• Treat predisposing conditions (athlete's foot, venous eczema, lymphedema) 1
• Consider prophylactic antibiotic therapy with delayed-release penicillin 3
• Address chronic edema through elevation, compression, and treatment of venous insufficiency 1

Special Considerations

Systemic corticosteroids may be considered as adjunctive treatment in uncomplicated cases to accelerate symptom resolution, though this is not standard practice 1

Outpatient treatment is appropriate for uncomplicated cases without comorbidities or unfavorable social context, given the excellent outcomes and low yield of diagnostic testing 4, 3