Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Erysipelas Treatment & Management

  • Author: Loretta Davis, MD; Chief Editor: William D James, MD  more...
 
Updated: Jun 29, 2016
 

Approach Considerations

While most cases of erysipelas resolve without sequelae following appropriate antibiotic therapy, prompt treatment is crucial because of potentially rapid progression. Aside from administration of antibiotics, patient care includes the following:

  • Symptomatic treatment of aches and fever
  • Hydration (oral intake if possible)
  • Cold compresses
  • Elevation and rest of the affected limb: 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

Surgical care

Debridement is necessary only in severe infections with necrosis or gangrene.

Inpatient care

Hospitalization for close monitoring and intravenous antibiotics is recommended in severe cases and for infants, elderly persons, and patients who are immunocompromised. Inpatient care is also recommended for patients who are unlikely to complete the course of treatment as a result of psychosocial reasons and for those with significant comorbidities.

Next

Pharmacologic Treatment

Streptococci cause most cases of erysipelas; thus, penicillin has remained first-line therapy.[17, 18] Penicillin administered orally or intramuscularly is sufficient for most cases of classic erysipelas and should be given for 5 days, but if the infection has not improved, treatment duration should be extended.

A first-generation cephalosporin may be used if the patient has an allergy to penicillin. Cephalosporins may cross-react with penicillin and should be used with caution in patients with a history of severe penicillin allergy, such as anaphylaxis. Clindamycin remains a therapeutic option, although clindamycin-resistant group B streptococcal isolates are well documented.[19] Erythromycin-resistant group B streptococcal isolates are common.[19]

Coverage for Staphylococcus 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.[4]

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.[20]  The US Food and Drug Administration (FDA) has not approved these drugs in the United States, but they are in use in Europe.

The FDA approved 3 antibiotics, oritavancin (Orbactiv), dalbavancin (Dalvance), and tedizolid (Sivextro), for the treatment of acute bacterial skin and skin structure infections. These agents are active against Staphylococcus aureus (including methicillin-susceptible and methicillin-resistant S aureus [MSSA, MRSA] isolates), Streptococcus pyogenes, Streptococcus agalactiae, and Streptococcus anginosus group (includes Streptococcus anginosus, Streptococcus intermedius, and Streptococcus constellatus), among others. For complete drug information, including dosing, see the following monographs:

Previous
Next

Activity

Patients with acute infections involving the extremities should be encouraged to limit their activity and to keep affected limbs elevated to decrease swelling.

Previous
Next

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, consultation with an infectious disease specialist is advisable. Given atypical presentations of many cutaneous diseases, dermatologist consultation should be considered in cases in which the diagnosis is in doubt.

Previous
Next

Long-term Management

Patients with recurrent erysipelas should be educated regarding local antisepsis and general wound care. Predisposing lower extremity skin lesions (eg, tinea pedis, toe web intertrigo, stasis ulcers, asteatotic dermatitis) 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 long-term in patients with lower extremity edema. Long-term management of lymphedema is essential.

Long-term prophylactic antibiotic therapy generally is accepted.[21] Treatment regimens should be tailored to the patient. One regimen is benzathine penicillin G at 2.4 mU intramuscularly every 2-4 weeks for up to 2 years.[22] Oral penicillin or erythromycin twice daily for 4-52 weeks is an alternate regimen.[23]

Previous
 
 
Contributor Information and Disclosures
Author

Loretta Davis, MD Professor, Department of Internal Medicine, Division of Dermatology, Medical College of Georgia

Loretta Davis, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

John A Cole, MD Dermatologist, Private Practice, Valdosta, GA

John A Cole, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Keith Benbenisty, MD Consulting Staff, Associates in Dermatology, MDs, PA

Disclosure: Nothing to disclose.

Francis Counselman, MD Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary; Assistant Professor, Department of Family Medicine, McGill University

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Christen M Mowad, MD Associate Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Dermatological Association, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, New York Academy of Medicine, and Sigma Xi

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Michael J Wells, MD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

References
  1. Bonnetblanc JM, Bedane C. Erysipelas: recognition and management. Am J Clin Dermatol. 2003. 4(3):157-63. [Medline].

  2. Bernard P. Management of common bacterial infections of the skin. Curr Opin Infect Dis. 2008 Apr. 21(2):122-8. [Medline].

  3. Matz H, Orion E, Wolf R. Bacterial infections: uncommon presentations. Clin Dermatol. 2005 Sep-Oct. 23 (5):503-8. [Medline].

  4. 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].

  5. Jorup-Ronstrom C. Epidemiological, bacteriological and complicating features of erysipelas. Scand J Infect Dis. 1986. 18(6):519-24. [Medline].

  6. Vignes S, Dupuy A. Recurrence of lymphoedema-associated cellulitis (erysipelas) under prophylactic antibiotherapy: a retrospective cohort study. J Eur Acad Dermatol Venereol. 2006 Aug. 20(7):818-22. [Medline].

  7. Pereira de Godoy JM, Azoubel LM, Guerreiro Godoy Mde F. Erysipelas and lymphangitis in patients undergoing lymphedema treatment after breast-cancer therapy. Acta Dermatovenerol Alp Panonica Adriat. 2009 Jun. 18(2):63-5. [Medline].

  8. Damstra RJ, van Steensel MA, Boomsma JH, Nelemans P, Veraart JC. Erysipelas as a sign of subclinical primary lymphoedema: a prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg. Br J Dermatol. 2008 Jun. 158(6):1210-5. [Medline].

  9. Ellis H. The last year before the dawn of antibiotics. Br J Hosp Med (Lond). 2009 Aug. 70(8):475. [Medline].

  10. Pereira de Godoy JM, Galacini Massari P, Yoshino Rosinha M, Marinelli Brandão R, Foroni Casas AL. Epidemiological data and comorbidities of 428 patients hospitalized with erysipelas. Angiology. 2010 Jul. 61(5):492-4. [Medline].

  11. Morris AD. Cellulitis and erysipelas. Clin Evid (Online). 2008 Jan 2. 2008:[Medline]. [Full Text].

  12. Gunderson CG, Chang JJ. Risk of deep vein thrombosis in patients with cellulitis and erysipelas: a systematic review and meta-analysis. Thromb Res. 2013 Sep. 132(3):336-40. [Medline].

  13. Coste N, Perceau G, Leone J, et al. Osteoarticular complications of erysipelas. J Am Acad Dermatol. 2004 Feb. 50(2):203-9. [Medline].

  14. Bien P, De Anda C, Prokocimer P. Comparison of Digital Planimetry and Ruler Technique To Measure ABSSSI Lesion Sizes in the ESTABLISH-1 Study. Surg Infect (Larchmt). 2014 Apr. 15(2):105-10. [Medline].

  15. Grosshans EM. The red face: erysipelas. Clin Dermatol. 1993 Apr-Jun. 11(2):307-13. [Medline].

  16. Leppard BJ, Seal DV, Colman G, Hallas G. The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. Br J Dermatol. 1985 May. 112(5):559-67. [Medline].

  17. Bishara J, Golan-Cohen A, Robenshtok E, Leibovici L, Pitlik S. Antibiotic use in patients with erysipelas: a retrospective study. Isr Med Assoc J. 2001 Oct. 3(10):722-4. [Medline].

  18. Vos MD, Bos RR, Vissink A. [A sudden redness and swelling of the face]. Ned Tijdschr Tandheelkd. 2009 Jul. 116(7):383-6. [Medline].

  19. Phares CR, Lynfield R, Farley MM, Mohle-Boetani J, Harrison LH, Petit S, et al. Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. JAMA. 2008 May 7. 299 (17):2056-65. [Medline].

  20. Bernard P, Plantin P, Roger H, et al. Roxithromycin versus penicillin in the treatment of erysipelas in adults: a comparative study. Br J Dermatol. 1992 Aug. 127(2):155-9. [Medline].

  21. Oh CC, Ko HC, Lee HY, Safdar N, Maki DG, Chlebicki MP. Antibiotic prophylaxis for preventing recurrent cellulitis: A systematic review and meta-analysis. J Infect. 2014 Feb 24. [Medline].

  22. Sjoblom AC, Eriksson B, Jorup-Ronstrom C, Karkkonen K, Lindqvist M. Antibiotic prophylaxis in recurrent erysipelas. Infection. 1993 Nov-Dec. 21(6):390-3. [Medline].

  23. [Guideline] Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clin Infect Dis. 2014 Jul 15. 59(2):e10-52. [Medline]. [Full Text].

 
Previous
Next
 
Well-demarcated, erythematous plaque of erysipelas. Courtesy of the US Centers for Disease Control and Prevention.
Facial erysipelas exhibiting classic fiery-red plaque with raised, well-demarcated borders.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.