eMedicine Specialties > Dermatology > Bacterial Infections

Cellulitis

Author: Giuseppe Micali, MD, Head, Professor, Department of Dermatology, University of Catania School of Medicine, Italy
Coauthor(s): Vinod K Dhawan, MD, FACP, FRCP(C), Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Professor of Medicine, Charles Drew University of Medicine and Science; Chief, Division of Infectious Diseases, MLK-Harbor Hospital; Maria R Nasca, MD, PhD, Assistant Professor, Department of Dermatology, University of Catania School of Medicine, Italy
Contributor Information and Disclosures

Updated: Mar 5, 2009

Introduction

Background

The term "cellulitis" is commonly used to indicate a nonnecrotizing inflammation of the dermis and hypodermis related to acute infection that does not involve the fascia or muscles, and that is characterized by localized pain, swelling, tenderness, erythema, and warmth.

Pathophysiology

Cellulitis usually follows a break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound. Facial cellulitis of odontogenic origin may also occur. Patients with toe web intertrigo and/or tinea pedis and those with lymphatic obstruction, venous insufficiency, pressure ulcers, and obesity are particularly vulnerable to recurrent episodes of cellulitis.1,2,3,4 Organisms on the skin and its appendages gain entrance to the dermis and multiply to cause cellulitis.

The vast majority of cases are caused by Streptococcus pyogenes or Staphylococcus aureus. Occasionally, cellulitis may be caused by the emergence of subjacent osteomyelitis. Cellulitis may rarely result from the metastatic seeding of an organism from a distant focus of infection, especially in immunocompromised individuals. This is particularly common in cellulitis due to Streptococcus pneumoniae and marine vibrios. Neisseria meningitidis, Pseudomonas aeruginosa, Brucella species, and Legionella species have also been reported as rare causes of cellulitis resulting from hematogenous spread.5

Frequency

United States

Because cellulitis is not a reportable disease, the exact prevalence is uncertain; however, it is a relatively common infection. A 2006 study found an incidence rate of 24.6 cases per 1000 person-years.6 In a large epidemiological hospital-based study on skin, soft tissue, bone, and joint infections, 37.3% patients were identified as having cellulitis.7

International

Cellulitis has been found to account for approximately 3% of emergency medical consultations at one United Kingdom district general hospital.

Mortality/Morbidity

Cellulitis generally is a localized infection. Most patients treated appropriately recover completely. Mortality is rare (5%) but may occur in neglected cases or when cellulitis is due to highly virulent organisms (eg, P aeruginosa). Factors associated with an increased risk of death are the presence of concurrent illness (eg, congestive heart failure, morbid obesity, hypoalbuminemia, renal insufficiency) or complications (eg, shock).8

Race

No racial predilection has been noted.

Sex

No predilection for either sex is usually reported, although a higher incidence among males has been reported in some studies.6,9

Age

No age predilection is usually described; however, studies found a higher incidence of cellulitis in general among individuals older than 45 years.2,6,9 Moreover, cellulitis at certain anatomic sites may show a predilection for persons in certain age groups.

  • Facial cellulitis is more common in children younger than 3 years.
  • Perianal cellulitis is predominantly a disease of children.10

Clinical

History

The incubation period is somewhat organism dependent. Postoperative cellulitis at the surgical site due to group A beta-hemolytic streptococci may develop rather rapidly. On the other hand, cellulitis due to staphylococci usually is delayed in onset.

  • Patients report local pain and swelling at the site of cellulitis.
  • The patient may report a history of trauma to the site. Severe bacterial cellulitis may occur as a postsurgical complication, such as following hip replacement11 or liposuction, or secondary to lymphatic occlusion following either radical mastectomy12,13 or conservative breast surgery14 ; impaired lymphatic drainage and edema are also considered predisposing factors to leg cellulitis following saphenous vein resection for coronary artery bypass.15 However, cellulitis may follow a trivial injury to the skin (eg, scratch, abrasion, animal bite, intravenous or subcutaneous drug injection, body piercing).16,17,18 Cellulitis has also rarely been reported as a possible postprocedural complication of radiation therapy.19
  • Fever is common, and chills may be noted, particularly if suppuration has occurred.
  • Malaise may be present.

Physical

The following images show the clinical appearance of cellulitis:
 

Cellulitis involving the hand.

Cellulitis involving the hand.

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Cellulitis involving the hand.

Cellulitis involving the hand.


Cellulitis involving the lower extremity.

Cellulitis involving the lower extremity.

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Cellulitis involving the lower extremity.

Cellulitis involving the lower extremity.


Cellulitis involving the abdominal wall.

Cellulitis involving the abdominal wall.

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Cellulitis involving the abdominal wall.

Cellulitis involving the abdominal wall.


  • Involved sites are red, hot, swollen, and tender.
  • Unlike erysipelas, the borders are not elevated or sharply demarcated.
  • Lymphangitis, regional lymphadenopathy, or both may be present.
  • Malaise, chills, fever, and toxicity may occur.
  • In severe cases, patients may develop hypotension.
  • Local suppuration may follow if therapy is delayed.
  • Overlying skin may develop areas of necrosis.
  • The most commonly involved site is the leg.6,20
  • Perianal cellulitis due to group A streptococci is usually observed among children with perianal fissures. It is characterized by perianal erythema and pruritus, purulent secretions, painful defecation, and bleeding in the stools.10
  • Pneumococcal facial cellulitis occurs primarily in young children who are at risk for pneumococcal bacteremia.21,22 It may manifest as 2 distinctive clinical syndromes, as follow:
    • Extremity involvement in individuals with diabetes mellitus or substance abuse
    • Head, neck, and upper torso involvement in individuals with systemic lupus erythematosus, nephrotic syndrome, or hematologic disorders

Causes

  • In immunocompetent adults, cellulitis is usually due to S pyogenes and, occasionally, S aureus.5,8,23,24 Isolation of methicillin-resistant S aureus (MRSA) is steadily increasing, especially among intravenous drug users, HIV infected patients, prisoners, athletes, military trainees, and male homosexuals.4,25 Bacterial strains may also show multiple resistance to other standard antibiotic treatments, including erythromycin.
  • In children, the most common cause of cellulitis is S aureus. Other causes include S pyogenes (perianal cellulitis), Haemophilus influenzae, and S pneumoniae.
  • Recurrent staphylococcal cellulitis may occur in patients with nasal carriage of staphylococci and those with Job syndrome. S aureus is also the leading cause of soft tissue infections in persons who abuse injection drugs.26
  • Recurrent cellulitis due to streptococci may be observed in patients with chronic lymphedema (eg, from lymph node dissection, irradiation, Milroy disease, elephantiasis).23,27 Streptococcal infections are also common in injection drug users.28
  • Non–group A streptococci (ie, groups B, C, and G) are commonly implicated in cellulitis in patients with lymphatic obstruction or venectomy for coronary artery bypass graft.15,29
  • S pneumoniae is an uncommon cause of cellulitis in adults.22,30,31 Pneumococcal cellulitis may occur from bacteremia. In a review of pneumococcal skin infection in adults, all such patients had an underlying chronic illness or were immunocompromised by drug or alcohol abuse.32 Pneumococcal facial cellulitis occurs primarily in young children at risk for pneumococcal bacteremia.21,33
  • Patients who are immunocompromised with granulocytopenia, such as renal transplant recipients, may develop cellulitis due to infection with other organisms, including gram-negative bacilli (eg, Pseudomonas, Proteus, Serratia, Enterobacter, Citrobacter), anaerobes, other opportunistic pathogens (eg, Helicobacter cinaedi, Fusarium species), mycobacteria, and fungi (eg, Cryptococcus).24,34,35,36,37,38,39,40,41 Preseptal cellulitis caused by dermatophytes is rarely observed, mostly in the pediatric age group.42 Persistent cellulitis due to Cryptococcus neoformans infection has also been reported in a patient receiving renal dialysis.43
  • Escherichia coli may be responsible for cellulitis in patients with nephrotic syndrome.44
  • Cellulitis from unusual bacterial species, including Enterococcus faecalis, Enterobacteriaceae, and Bacteroides and Clostridium species, may be observed following subcutaneous injections of illegal drugs.45 If Clostridium species or other anaerobes (Bacteroides, Peptostreptococcus, Peptococcus, Prevotella) cause the infection, crepitant cellulitis is often observed clinically.5
  • Other uncommon causes of cellulitis include Neisseria meningitidis; Mycobacterium avium-intracellulare; Pasteurella multocida, following animal bites; Aeromonas hydrophilia, following contact with fresh water46 ; Streptococcus iniae, a fish pathogen causing infections in aquaculture farms; and Chromobacterium violaceum and Vibrio vulnificus, following contact with seawater. Cellulitis from marine vibrios in hepatopathic patients may also follow ingestion of contaminated raw oysters.47,48,49,50,51,52,53,54,55 Acinetobacter baumannii is an emerging multidrug-resistant pathogen that causes hospital-acquired soft tissue infections, including cellulitis, following gunshot wounds or use of invasive devices.56 H influenzae has become a rare cause of buccal cellulitis in children after the introduction of the H influenzae type B vaccine.57,58

More on Cellulitis

Overview: Cellulitis
Differential Diagnoses & Workup: Cellulitis
Treatment & Medication: Cellulitis
Follow-up: Cellulitis
Multimedia: Cellulitis
References
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References

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Further Reading

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Keywords

cellulitis, infection of the skin, skin infection, soft tissue infection, infection of the soft tissue, Streptococcus pyogenes, S pyogenes, Staphylococcus aureus, S aureus

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Contributor Information and Disclosures

Author

Giuseppe Micali, MD, Head, Professor, Department of Dermatology, University of Catania School of Medicine, Italy
Giuseppe Micali, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Vinod K Dhawan, MD, FACP, FRCP(C), Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Professor of Medicine, Charles Drew University of Medicine and Science; Chief, Division of Infectious Diseases, MLK-Harbor Hospital
Vinod K Dhawan, MD, FACP, FRCP(C) is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Royal College of Physicians and Surgeons of Canada
Disclosure: Pfizer Inc None None

Maria R Nasca, MD, PhD, Assistant Professor, Department of Dermatology, University of Catania School of Medicine, Italy
Disclosure: Nothing to disclose.

Medical Editor

Sungnack Lee, MD, Vice President of Medical Affairs, Professor, Department of Dermatology, Ajou University School of Medicine, Korea
Sungnack Lee, MD is a member of the following medical societies: American Dermatological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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.

 
 
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