From the Guidelines
Recurrent cellulitis in a 21-year-old should be managed with both acute treatment and preventive measures, prioritizing the identification and treatment of predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities, as recommended by the Infectious Diseases Society of America 1. For acute episodes, prescribe oral antibiotics such as cephalexin 500 mg four times daily for 7-10 days, or clindamycin 300 mg four times daily if MRSA is suspected or the patient has a penicillin allergy.
Key Considerations
- Daily hygiene measures are crucial, including gentle skin cleansing, moisturizing dry areas, and treating any breaks in the skin promptly.
- For patients with three or more episodes per year, prophylactic antibiotics may be warranted, such as penicillin V 250 mg twice daily or erythromycin 250 mg twice daily for 6-12 months, as suggested by the guidelines 1.
- Compression stockings can help if there's associated edema or venous insufficiency.
- Recurrent cellulitis often occurs because bacteria persist in the skin or underlying tissue, or because predisposing factors aren't adequately addressed.
Prevention and Management
- Address underlying risk factors like skin conditions (tinea pedis, eczema), obesity, or venous insufficiency.
- Consider referral to infectious disease or dermatology to rule out other conditions that may mimic cellulitis or to identify unusual pathogens if episodes continue despite these measures.
- Elevation of the affected area and treatment of predisposing factors are recommended, as they can help reduce the incidence of recurrent infection 1.
- The use of systemic corticosteroids as an optional adjunct for treatment of uncomplicated cellulitis and erysipelas in selected adult patients may be considered, as they have been shown to hasten resolution and shorten healing time 1.
From the Research
Recurrent Cellulitis Overview
- Recurrent cellulitis is a challenging clinical condition that affects up to 47% of patients after the first episode, especially those with predisposing risk factors 2.
- Conditions that commonly increase the risk of cellulitis include local and systemic modifiable and nonmodifiable factors, such as chronic edema, venous disease, dermatomycosis, and obesity 3.
Risk Factors and Management
- Risk factors, if present, need to be targeted in association with antibiotic prophylaxis to prevent recurrence 2.
- Management of underlying predisposing conditions is crucial to prevent recurrence, in addition to evaluation of pharmacological measures 2.
- Non-antibiotic measures should be first-line in prevention, and antibiotic prophylaxis is effective but limited to non-purulent cellulitis where risk factors are appropriately managed 3.
Treatment and Prevention
- Penicillin V is the preferred antibiotic for prevention, but other antibiotics and new drugs can be considered in cases of β-lactam allergy, intolerance, or failure 2.
- A pill in pocket approach with the use of oral tedizolid has been discussed as a unique treatment approach for preventing severe cellulitis 4.
- Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit 5.
Diagnosis and Challenges
- Cellulitis is a clinical diagnosis based on the history of present illness and physical examination, and lacks a gold standard for diagnosis 6.
- Cellulitis can be difficult to diagnose due to a number of infectious and non-infectious clinical mimickers, such as venous stasis dermatitis, contact dermatitis, eczema, lymphedema, and erythema migrans 6.
- Microbiological diagnosis is often unobtainable due to poor sensitivity of culture specimens 6.