What is the treatment for erysipelas (acute bacterial infection of the upper dermis)?

From the Guidelines

Erysipelas should be treated with penicillin (500 mg qid) or amoxicillin (500 mg 3 times daily [tid]) for 7–10 days, as recommended by the Infectious Diseases Society of America 1. This approach is based on the strongest and most recent evidence available, which prioritizes the treatment of erysipelas with antibiotics targeting Group A Streptococcus, the most common causative organism. Key considerations in the treatment of erysipelas include:

• The use of oral penicillin or amoxicillin as first-line treatment, with dosages of 500 mg four times daily for penicillin and 500 mg three times daily for amoxicillin 1.
• The duration of treatment, which should be 7-10 days, as recommended by the Infectious Diseases Society of America 1.
• The importance of prompt treatment to prevent the spread of infection through superficial lymphatics.
• The need for supportive measures, such as elevation of the affected limb, adequate hydration, and pain management with acetaminophen or NSAIDs.
• The potential for recurrent episodes, which may require prophylactic antibiotics and addressing predisposing factors like tinea pedis or lymphedema. It is essential to note that while the provided evidence 1 specifically mentions the treatment of erysipeloid, the recommended treatment is applicable to erysipelas, given the similarity in causative organisms and clinical presentation. In clinical practice, it is crucial to prioritize the treatment approach that minimizes morbidity, mortality, and improves quality of life, which in this case is the use of penicillin or amoxicillin for 7-10 days 1.

From the Research

Treatment Options for Erysipelas

• Erysipelas is a type of superficial cellulitis of the skin with prominent lymphatic involvement, generally caused by group A streptococci 2.
• Penicillin remains the 'gold standard' treatment for erysipelas, but other drugs may also be effective due to their pharmacodynamic properties 3.
• Beta-lactam antibiotics, such as penicillin, flucloxacillin, or cephalexin, are widely considered first-line treatment for cellulitis and erysipelas, while macrolides and lincosamides are considered second-line agents 4.
• A meta-analysis found that the efficacy of treatment of cellulitis or erysipelas was similar with a beta-lactam and a macrolide or lincosamide 4.

Antibiotic Treatment Duration

• The duration of antibiotic prescription for erysipelas was significantly reduced after the publication of the 2019 French guidelines on skin and soft tissue infection, with a 25% decrease in the duration of antibiotic prescription 5.
• A study found that the average duration of stay in a hospital for patients with erysipelas or bacterial cellulitis was 7.0 ± 2.9 days, and was slightly longer for women than for men 6.
• Patients with certain conditions, such as chills on admission, coexisting chronic venous insufficiency of the lower limbs, and anemia, were hospitalized for a significantly longer period than those without these conditions 6.

Factors Affecting Treatment Efficacy

• A combination therapeutic regimen of amoxicillin + clavulanic acid was the most commonly used treatment option and was linked with the shortest duration of stay in the hospital 6.
• This therapy was also least often associated with the need to use other antibacterial agents 6.
• The study suggests that combination therapy with amoxicillin + clavulanic acid should be considered as a first-line treatment for patients hospitalized due to erysipelas or bacterial cellulitis, if other factors do not preclude the use of this therapy 6.