From the Guidelines
Patients with cellulitis and bullae require prompt evaluation and management to rule out underlying severe infections such as necrotizing fasciitis. A computed tomography (CT) scan is recommended to assess for underlying abscesses or necrotizing fasciitis, particularly if signs of severe infection are present, such as fever, tachycardia, or significant pain 1.
- Key features suggesting severe infection include:
- Severe pain disproportionate to physical findings
- Bullous lesions
- Skin necrosis or ecchymoses
- Systemic toxicity, often with altered mental status
- Imaging studies, such as CT scans, can provide useful information when the diagnosis is uncertain, but should not delay surgical consultation and intervention 1.
- Surgical consultation is advised to assess the need for potential debridement or drainage of any identified collections 1.
- Initial empiric antibiotic therapy with intravenous antibiotics, such as ceftriaxone or cefepime, is recommended, with consideration of adding vancomycin if methicillin-resistant Staphylococcus aureus (MRSA) is suspected 1. Clinical judgment remains the most important element in diagnosis, and a high index of suspicion for necrotizing fasciitis is crucial in patients with severe infections 1.
From the Research
Diagnosis and Treatment of Cellulitis with Bullae
- The diagnosis of cellulitis should be made only after a thorough evaluation of all possible differential diagnoses, as the accuracy of this diagnosis is approximately only 33% 2.
- Cellulitis may be a primary process or a secondary process incited by a subcutaneous process, such as an abscess, tenosynovitis, necrotizing fasciitis, and osteomyelitis 2.
- A comprehensive treatment approach may include systemic antimicrobials, as well as surgical options and compression therapy 2.
Role of Computed Tomography (CT) Scan
- The exact role of IV contrast-enhanced computed tomography (CT) in the diagnosis of necrotizing soft tissue infections (NSTIs) has not yet been established, but it can reliably rule out the need for surgical intervention in patients with initial suspicion of NSTI 3.
- A negative IV contrast-enhanced CT scan can reliably rule out the need for surgical intervention in patients with initial suspicion of NSTI, with a sensitivity of 100% and a negative predictive value of 100% 3.
- CT fistulography can be used to diagnose and determine the extent of abnormal channels, such as enterocutaneous fistula, and can rule out ECF in cases presenting as cellulitis if examinations are suggestive 4.
Surgical Consultation
- Surgical consultation may be necessary in cases of cellulitis with bullae, especially if there is suspicion of underlying conditions such as abscess, tenosynovitis, necrotizing fasciitis, or osteomyelitis 2.
- Surgical exploration may be required to confirm the diagnosis and provide appropriate treatment, especially in cases where CT scan results are positive for NSTI or other underlying conditions 3.
- The decision to perform surgical exploration should be based on clinical judgment, taking into account the results of CT scans and other diagnostic tests 5.