Treatment of Facial Erysipelas
Penicillin, administered either orally or parenterally depending on clinical severity, is the treatment of choice for facial erysipelas caused by Group A Streptococcus pyogenes. 1
First-Line Treatment Approach
Mild to Moderate Cases (Outpatient)
- Penicillin V 500 mg orally every 6-8 hours for 5-7 days is the standard first-line treatment for uncomplicated facial erysipelas 2, 3
- Alternatively, amoxicillin 500 mg three times daily for 5-7 days is equally effective 2
- The Infectious Diseases Society of America gives this recommendation an A-I grade (good evidence, should always be offered) 1
- Five days of treatment is as effective as 10 days if clinical improvement is evident by day 5 2, 3
Severe Cases (Hospitalization Required)
- Intravenous penicillin G should be used for severe presentations 2, 4
- Hospitalization criteria include: severe local signs (blisters, skin detachment), systemic signs (fever >38°C, tachycardia >90 bpm, tachypnea >24 rpm), immunocompromised status, or failure of previous oral treatment 3
Penicillin-Allergic Patients
For Severe Penicillin Allergy
- Clindamycin is the preferred alternative: 300-450 mg orally three times daily or 600 mg IV every 8 hours 2, 3
- Note that 99.5% of S. pyogenes strains remain susceptible to clindamycin, and 100% remain susceptible to penicillin 1
- Vancomycin 30 mg/kg/day IV in 2 divided doses is another effective option for severe cases with penicillin allergy 2
Alternative Options (Less Preferred)
- Erythromycin 250 mg four times daily may be used, but macrolide resistance in S. pyogenes has increased from 4-5% (1996-1998) to 8-9% (1999-2001) 1
- This makes macrolides less reliable than previously 4
Critical Adjunctive Measures
Essential Supportive Care
- Elevation of the affected facial area to promote drainage of edema and inflammatory substances 2
- Identify and treat the entry point (trauma, eczema, fungal infections) to prevent recurrence 2
- Bed rest is important during acute treatment 4
Treatment Duration Considerations
- For uncomplicated cases with clinical improvement, 5-7 days is sufficient 2, 3
- For complicated cases or those with comorbidities, complete 10 days of treatment 2
- Therapy must be sufficient to eliminate the organism to prevent sequelae of streptococcal disease 5
Important Clinical Pitfalls
Diagnostic Considerations
- Blood cultures have extremely low yield (positive in only 3% of cases) and are generally not necessary for typical facial erysipelas 2, 6
- Skin aspirates are unhelpful in 75-80% of cellulitis cases 1
- Diagnosis is clinical, based on the characteristic fiery red, tender, painful plaque with well-demarcated edges 1
When to Consider MRSA Coverage
- If the patient has risk factors for community-acquired MRSA or fails to respond to initial penicillin therapy within 24-48 hours, consider empiric MRSA coverage with vancomycin, linezolid, or daptomycin 1, 2
- However, classic erysipelas is caused by streptococci, not S. aureus, so this is uncommon 1
Prevention of Recurrence
Address Predisposing Factors
- Treat underlying conditions: athlete's foot, venous eczema, lymphedema 2
- Maintain well-hydrated skin with emollients 2
- Reduce underlying edema through limb elevation, compression stockings, or pneumatic pressure pumps 2
- Recurrence occurs in up to 40% of patients and is the most distressing complication 4, 7
Special Note on Recurrent Cases
- Long-term prophylactic antibiotics may be needed for patients with frequent recurrences 4
- Intracellular streptococcal persistence may explain why penicillin prophylaxis sometimes fails to prevent recurrence, as penicillins do not achieve sufficient intracellular concentrations 7
Monitoring and Follow-Up
- Re-evaluate patients within 24-48 hours if treated as outpatients to verify clinical response 1
- Progression despite antibiotics suggests either resistant organisms or a deeper, more serious infection than initially recognized 1
- Mean duration of fever after penicillin initiation is typically 1.7 days 8