Erysipelas Treatment & Management

  • Author: Loretta Davis, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 11, 2010
 

Medical Care

  • Elevation and rest of the affected limb are recommended in erysipelas treatment 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.[8, 9] Penicillin administered orally or intramuscularly is sufficient for most cases of classic erysipelas and should be given for 10-20 days.
  • A first-generation 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 and should be used with caution in patients with a history of severe penicillin allergy such as 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 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.[6]
  • 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.[10] 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, toe web intertrigo, 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 long term in patients with lower extremity edema. Long-term management of lymphedema is essential. 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 G at 2.4 MU intramuscularly every 3 weeks for up to 2 years.[11] Two-week intervals have also been used.[2]
  • Also see a clinical guideline summary from the Infectious Diseases Society of America, Practice guidelines for the diagnosis and management of skin and soft-tissue infections.[12]
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Surgical Care

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

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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.

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Activity

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

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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  Resident Physician, Division of Dermatology, University of Florida Health Science Center, Gainesville

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

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-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, and Sigma Xi

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center

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.

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, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

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

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

  3. 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. Jun 2009;18(2):63-5. [Medline].

  4. [Best Evidence] 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. Jun 2008;158(6):1210-5. [Medline].

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

  6. 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].

  7. 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].

  8. 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].

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

  10. Bernard P, Plantin P, Roger H, 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].

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

  12. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. Nov 15 2005;41(10):1373-406. [Medline].

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

  14. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. Jan 25 1996;334(4):240-5. [Medline].

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

  16. Bratton RL, Nesse RE. St. Anthony's Fire: diagnosis and management of erysipelas. Am Fam Physician. Feb 1 1995;51(2):401-4. [Medline].

  17. Chartier C, Grosshans E. Erysipelas. Int J Dermatol. Sep 1990;29(7):459-67. [Medline].

  18. Chartier C, Grosshans E. Erysipelas: an update. Int J Dermatol. Nov 1996;35(11):779-81. [Medline].

  19. Elston DM. Epidemiology and prevention of skin and soft tissue infections. Cutis. May 2004;73(5 Suppl):3-7. [Medline].

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

  21. Hammar H, Wanger L. Erysipelas and necrotizing fasciitis. Br J Dermatol. Apr 1977;96(4):409-19. [Medline].

  22. Ronnen M, Suster S, Schewach-Millet M, Modan M. Erysipelas. Changing faces. Int J Dermatol. Apr 1985;24(3):169-72. [Medline].

  23. Torok L. Uncommon manifestations of erysipelas. Clin Dermatol. Sep-Oct 2005;23(5):515-8. [Medline].

  24. Zeglaoui F, Dziri C, Mokhtar I, 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].

 
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Facial erysipelas exhibiting classic fiery-red plaque with raised, well-demarcated borders.
 
 
 
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