What are the typical signs and symptoms of cellulitis?

Signs and Symptoms of Cellulitis

Cellulitis presents with rapidly spreading erythema, swelling, warmth, and tenderness of the skin, typically with poorly defined borders that distinguish it from erysipelas. 1, 2

Primary Clinical Features

The hallmark presentation includes four cardinal signs that develop over hours to days:

• Erythema (redness) that spreads diffusely across the affected area with poorly demarcated borders 2, 3
• Edema (swelling) of the deep dermis and subcutaneous tissue 3, 4
• Warmth over the affected skin surface 2, 5
• Tenderness and pain on palpation of the involved area 4, 5

Additional Cutaneous Manifestations

Beyond the cardinal signs, several distinctive skin changes may appear:

• "Peau d'orange" appearance (orange-peel texture) due to superficial cutaneous edema surrounding hair follicles, causing skin dimpling because follicles remain tethered to underlying dermis 1, 2
• Vesicles or bullae may develop in some cases 1
• Cutaneous hemorrhage in the form of petechiae or ecchymoses can occur 1
• Lymphangitis (red streaking) extending from the affected area toward regional lymph nodes 1, 2

Regional Lymph Node Involvement

• Inflammation and tenderness of regional lymph nodes draining the affected area is common 1, 2

Systemic Manifestations

While often mild, systemic features can precede visible skin changes:

• Fever may occur hours before skin abnormalities appear 1, 2
• Tachycardia (rapid heart rate) 1, 2
• Leukocytosis (elevated white blood cell count) 1, 2
• Confusion or altered mental status in severe cases 1, 2
• Hypotension indicating systemic toxicity 1, 2

Temporal Pattern

• Acute onset developing over hours to days, distinguishing cellulitis from chronic inflammatory conditions 4, 5
• Rapid spreading of erythema and swelling is characteristic 1, 3

Common Predisposing History

• Preceding skin trauma such as minor abrasion, insect bite, or injection site often serves as the portal of entry 6
• Local skin breakdown from tinea pedis, fissuring, or maceration in interdigital toe spaces 6

Critical Warning Signs Requiring Immediate Evaluation

Certain features suggest deeper or necrotizing infection and mandate urgent surgical consultation:

• Severe pain out of proportion to examination findings 6
• Skin anesthesia over the affected area 6
• "Wooden-hard" subcutaneous tissues suggesting fascial involvement 6
• Rapid progression despite appropriate antibiotics 6
• Bullous changes with hemorrhagic bullae 1
• Systemic toxicity with hypotension or organ dysfunction 6