eMedicine Specialties > Dermatology > Bacterial Infections
Erysipelas: Treatment & Medication
Updated: Feb 11, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
- Elevation and rest of the affected limb are recommended to reduce local swelling, inflammation, and pain.
- Saline wet dressings should be applied to ulcerated and necrotic lesions and changed every 2-12 hours, depending on the severity of the infection.
- Streptococci cause most cases of erysipelas; thus, penicillin has remained first-line therapy.4 Penicillin administered orally or intramuscularly is sufficient for most cases of classic erysipelas and should be given for 10-20 days.
- A cephalosporin or macrolide, such as erythromycin or azithromycin, may be used if the patient has an allergy to penicillin. Cephalosporins may cross-react with penicillin first-generation cephalosporins and should not be used in patients with a history of severe penicillin allergy, urticarial reactions, or anaphylaxis.
- Hospitalization for close monitoring and intravenous antibiotics is recommended in severe cases and in infants, elderly patients, and patients who are immunocompromised.
- Coverage for S aureus is not usually necessary for typical infections, but it should be considered in patients who do not improve with penicillin or who present with atypical forms of erysipelas, including bullous erysipelas. Some authors believe that facial erysipelas should be treated empirically with a penicillinase-resistant antibiotic, such as dicloxacillin or nafcillin, to cover possible S aureus infection, but supporting evidence for this recommendation is lacking.2
- Two drugs, roxithromycin and pristinamycin, have been reported to be extremely effective in the treatment of erysipelas. Several studies have demonstrated greater efficacy and fewer adverse effects with these drugs compared with penicillin.5 Currently, the Food and Drug Administration has not approved these drugs in the United States, but they are in use in Europe.
- Patients with recurrent erysipelas should be educated regarding local antisepsis and general wound care. Predisposing lower extremity skin lesions (eg, tinea pedis, stasis ulcers) should be treated aggressively to prevent superinfection. Use of compression stockings should be encouraged for as long as 1 month in previously healthy patients and for the long-term in patients with preexisting lower extremity edema. Long-term prophylactic antibiotic therapy generally is accepted, but no true guidelines are available. Treatment regimens should be tailored to the patient. One reported regimen is benzathine penicillin at 2.4 MU intramuscularly every 3 weeks for up to 2 years.6
Surgical Care
Debridement is necessary only in severe infections with necrosis or gangrene.
Consultations
Most patients with erysipelas respond very well to conventional antibiotic therapy. However, in atypical infections that are unresponsive to first- and second-line agents, an infectious disease consult may be useful.
Activity
Patients with acute infections involving the extremities should be encouraged to limit their activity and keep the limb elevated to decrease swelling.
Medication
The objective of pharmacotherapy is to reduce morbidity and to prevent complications.
Antibiotics
Penicillin is the standard therapy for typical erysipelas, although coverage for S aureus should be considered in the appropriate setting.
Penicillin (Wycillin, PenVeeK)
Penicillin G procaine (Wycillin) and penicillin VK (PenVeeK) currently are recommended as first-line agents, indicated for the treatment of moderately severe infections of skin and skin structure. In adults, administer penicillin G procaine by deep IM injection only into upper, outer quadrant of buttock. In infants and small children, the midlateral aspect of the thigh may be a better site for administration.
Adult
Penicillin G procaine: 0.6-1.2 million U IM bid for 10 d
Penicillin VK: 250-500 mg PO qid for 10-14 d
Pediatric
Penicillin G procaine:
<30 kg: 300,000 U/d
>30 kg: Administer as in adults
Penicillin VK:
<12 years: 25-50 mg/kg/d PO divided tid/qid; not to exceed 3 g/d
>12 years: Administer as in adults
Increases risk of bleeding when administered concurrently with warfarin; ethacrynic acid, aspirin, indomethacin, and furosemide may compete with penicillin G for renal tubular secretion, increasing penicillin serum concentrations; probenecid can increase effects; coadministration of tetracyclines can decrease effects; may increase methotrexate toxicity; may decrease contraceptive efficacy; may interfere with immunological response to live typhoid vaccine; concurrent administration with aminoglycoside therapy may result in inactivation of aminoglycoside (amikacin appears to possess greatest stability in presence of penicillins; in treatment of severely ill patients requiring both penicillin and aminoglycoside therapy, amikacin is aminoglycoside of choice)
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Never use IV route to administer penicillin G procaine; administer >10 d to eliminate organism and to prevent such complications as endocarditis and rheumatic fever.
Dicloxacillin (Dycill, Dynapen)
Treatment of infections caused by penicillinase-producing staphylococci. Penicillinase-resistant penicillin that will cover for S aureus.
Adult
125-500 mg PO qid for 10 d
Pediatric
<40 kg: 12.5 mg/kg/d PO q6h
>40 kg: 125 mg PO q6h
Probenecid may increase effect of penicillins; tetracyclines may decrease effect of penicillins with concurrent use
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Renal impairment; cross-sensitivity to other penicillin derivatives; breastfeeding; caution in impaired renal function
Nafcillin (Unipen)
Initial therapy for suspected penicillin G-resistant streptococcal or staphylococcal infections.
Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants.
Because of thrombophlebitis, particularly in elderly patients, administer parenterally only for short term (1-2 d); change to PO as clinically indicated.
Adult
1-2 g IV qid for 7 d
Infection due to S aureus, penicillinase-producing: 500 mg IV q4h; alternatively, 500 mg IM q4-6h
Severe infection: 1000 mg IV or IM q4h
Pediatric
0-4 kg: 10 mg/kg IM bid
4-40 kg: 25 mg/kg IM bid; alternatively, 100-200 mg/kg/d IV/IM in 4-6 divided doses
Children: 50 mg/kg/d PO divided qid
Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives; concomitant penicillin and aminoglycoside therapy reported to result in inactivation of aminoglycoside both in vivo and in vitro; nafcillin appears to decrease cyclosporine serum concentrations or interfere with cyclosporine assay
Documented hypersensitivity; hypersensitivity to corn or corn products; dextrose solutions may precipitate an allergic reaction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Renal impairment; cross-sensitivity to other penicillin derivatives; breastfeeding; >10 d treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); adverse reactions include hypokalemia and interstitial nephritis; history of significant allergies or asthma; increased risk for allergic reaction; diarrhea subsequent to nafcillin may be indicative of overgrowth of Clostridium difficile resulting in pseudomembranous colitis
Reports of proteinuria associated with high doses of nafcillin indicate this pseudoproteinuria is result of interaction between nafcillin and/or metabolites and quantitative reagents used in TCA (trichloroacetic acid) and sulfosalicylic acid method of urine protein analysis (semiquantitative dipstick technique for estimation of urinary protein [primarily albumin] does not produce this interaction); antibiotics that possess bacterial activity against Salmonella typhi organisms may interfere with immunological response to live typhoid vaccine (allow 24 h or more to elapse between administration of last dose of antibiotic and live typhoid vaccine)
Erythromycin (E-mycin, E.E.S., Eryc)
Macrolide used for penicillin-allergic individuals. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half total daily dose may be taken q12h. For more severe infections, double the dose.
Adult
250-500 mg PO qid for 10 d
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; hepatotoxicity or skin rash may occur; caution in breastfeeding
More on Erysipelas |
| Overview: Erysipelas |
| Differential Diagnoses & Workup: Erysipelas |
 Treatment & Medication: Erysipelas |
| Follow-up: Erysipelas |
| Multimedia: Erysipelas |
| References |
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References
Jorup-Rönström C. Epidemiological, bacteriological and complicating features of erysipelas. Scand J Infect Dis. 1986;18(6):519-24. [Medline].
Krasagakis K, Samonis G, Maniatakis P, Georgala S, Tosca A. Bullous erysipelas: clinical presentation, staphylococcal involvement and methicillin resistance. Dermatology. 2006;212(1):31-5. [Medline].
Leppard BJ, Seal DV, Colman G, Hallas G. The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. Br J Dermatol. May 1985;112(5):559-67. [Medline].
Bishara J, Golan-Cohen A, Robenshtok E, Leibovici L, Pitlik S. Antibiotic use in patients with erysipelas: a retrospective study. Isr Med Assoc J. Oct 2001;3(10):722-4. [Medline].
Bernard P, Plantin P, Roger H, Sassolas B, Villaret E, Legrain V, et al. Roxithromycin versus penicillin in the treatment of erysipelas in adults: a comparative study. Br J Dermatol. Aug 1992;127(2):155-9. [Medline].
Sjöblom AC, Eriksson B, Jorup-Rönström C, Karkkonen K, Lindqvist M. Antibiotic prophylaxis in recurrent erysipelas. Infection. Nov-Dec 1993;21(6):390-3. [Medline].
Coste N, Perceau G, Léone J, Young P, Carsuzaa F, Bernardeau K, et al. Osteoarticular complications of erysipelas. J Am Acad Dermatol. Feb 2004;50(2):203-9. [Medline].
Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. Jan 25 1996;334(4):240-5. [Medline].
Bonnetblanc JM, Bédane C. Erysipelas: recognition and management. Am J Clin Dermatol. 2003;4(3):157-63. [Medline].
Bratton RL, Nesse RE. St. Anthony's Fire: diagnosis and management of erysipelas. Am Fam Physician. Feb 1 1995;51(2):401-4. [Medline].
Chartier C, Grosshans E. Erysipelas. Int J Dermatol. Sep 1990;29(7):459-67. [Medline].
Chartier C, Grosshans E. Erysipelas: an update. Int J Dermatol. Nov 1996;35(11):779-81. [Medline].
Elston DM. Epidemiology and prevention of skin and soft tissue infections. Cutis. May 2004;73(5 Suppl):3-7. [Medline].
Grosshans EM. The red face: erysipelas. Clin Dermatol. Apr-Jun 1993;11(2):307-13. [Medline].
Hammar H, Wanger L. Erysipelas and necrotizing fasciitis. Br J Dermatol. Apr 1977;96(4):409-19. [Medline].
Ronnen M, Suster S, Schewach-Millet M, Modan M. Erysipelas. Changing faces. Int J Dermatol. Apr 1985;24(3):169-72. [Medline].
Török L. Uncommon manifestations of erysipelas. Clin Dermatol. Sep-Oct 2005;23(5):515-8. [Medline].
Zeglaoui F, Dziri C, Mokhtar I, Ezzine N, Kharfi M, Zghal M, et al. Intramuscular bipenicillin vs. intravenous penicillin in the treatment of erysipelas in adults: randomized controlled study. J Eur Acad Dermatol Venereol. Jul 2004;18(4):426-8. [Medline].
Further Reading
Keywords
non-necrotizing dermohypodermitis, acute bacterial dermohypodermitis
