eMedicine Specialties > Emergency Medicine > Infectious Diseases

Cellulitis

Author: Danny Lee Curtis, MD, Clinical Assistant Professor of Medicine, University of South Florida School of Medicine; Consulting Staff, James A. Haley Veterans' Hospital, Tampa, Florida
Contributor Information and Disclosures

Updated: Jul 8, 2009

Introduction

Background

The word cellulitis literally means inflammation of the cells. It generally indicates an acute spreading infection of the dermis and subcutaneous tissues resulting in pain, erythema, edema, and warmth.

Pathophysiology

Skin and subcutaneous tissues are involved when microorganisms, typically gram-positive bacteria, invade disrupted skin.

The skin disruption may be obvious, such as a laceration, fissure, or puncture wound. However, cellulitis frequently occurs in areas where no apparent injury exists. This is common in dry and irritated skin where microscopic breaks allow penetration of bacteria.

The infection triggers an inflammatory response that results in the clinically apparent pain, redness, warmth, and swelling.

Frequency

United States

An examination was made of visits by patients with skin and soft tissue infections (SSTIs) to physician offices, hospital outpatient departments, and emergency departments in the United States using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2005.1

  • Overall rates of visits increased for SSTIs increased from 32.1 to 48.1 visits per 1000 population, and reached 14.2 million by 2005.
  • Visits for abscess and cellulitis increased from 17.3 to 32.5 visits per 1000 population and accounted for more than 95% of the increase.

A study of an insurance database in Utah found the incidence of cellulitis to be 24.6 per  1000 person-years. The incidence was noted to be higher in males and in those individuals aged 45-64 years.2

International

A study in the United Kingdom utilizing the Hospital Episode Statistics database identified a 3-fold increase in hospital admissions for treatment of cellulitis and abscess for the period 1996-2006.3

Mortality/Morbidity

Cellulitis may progress to serious illness by uncontrolled spread contiguously or via the lymphatic or circulatory systems. Complications include lymphangitis, abscess formation, gangrenous cellulitis, necrotizing fasciitis, bacteremia, and sepsis.4

Race

No predilection for cellulitis exists.

Sex

There is no statistically significant difference in the incidence of cellulitis in men and women.5

Age

  • Facial cellulitis occurs more commonly in adults older than 50 years and in children aged 6 months to 3 years.
  • Perianal cellulitis occurs predominantly in children. (The term perianal cellulitis is somewhat of a misnomer, and the term perianal disease is preferred by some authors.)6
  • In a retrospective GeoSentinel Surveillance Network study of international travelers, cellulitis was more common in geriatric patients.7

Clinical

History

The patient may have a history of trauma or surgery causing a break in the skin or may have no discernible dermal injury. The infection typically develops over a period of several days.

  • Among those with peripheral vascular disease or diabetes, minor injuries or cracked skin in the feet or toes can serve as a source for infection.8
  • Foreign bodies passing through skin, such as intravenous catheters or orthopedic pins, can provide a portal of entry to infection.
  • In those with prior surgery involving lymph node dissection, such as mastectomy, no evidence of recent injury may be observed. However, these patients are prone to recurrent cellulitis in these areas.9
  • Cellulitis tends to recur in areas of previous infection. Often, there is no apparent tissue injury. This is particularly common in areas with impaired circulation from previous trauma or vascular injury.
  • Lower extremity edema predisposes the patient to the development of cellulitis.10

Physical

The appearance of cellulitis is shown in Media files 1-4.


Severe cellulitis of the leg in a woman aged 80 y...

Severe cellulitis of the leg in a woman aged 80 years. The cellulitis developed beneath a cast and was painful and warm to the touch. Significant erythema is evident. Margins are irregular but not raised. An ulcerated area is visible in the center of the photograph.

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Severe cellulitis of the leg in a woman aged 80 y...

Severe cellulitis of the leg in a woman aged 80 years. The cellulitis developed beneath a cast and was painful and warm to the touch. Significant erythema is evident. Margins are irregular but not raised. An ulcerated area is visible in the center of the photograph.



Severe cellulitis of the leg in a woman aged 80 y...

Severe cellulitis of the leg in a woman aged 80 years. This photograph shows intense erythema in a patchy distribution. An eroded area is visible near the center of the photograph.

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Severe cellulitis of the leg in a woman aged 80 y...

Severe cellulitis of the leg in a woman aged 80 years. This photograph shows intense erythema in a patchy distribution. An eroded area is visible near the center of the photograph.



Cellulitis complicating burns. Larger lesion is ...

Cellulitis complicating burns. Larger lesion is a second-degree burn and the smaller lesion is a first-degree burn, each with an expanding zone of erythema consistent with cellulitis.

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Cellulitis complicating burns. Larger lesion is ...

Cellulitis complicating burns. Larger lesion is a second-degree burn and the smaller lesion is a first-degree burn, each with an expanding zone of erythema consistent with cellulitis.



Mild cellulitis with a fine lacelike pattern of e...

Mild cellulitis with a fine lacelike pattern of erythema. This lesion was only slightly warm and caused minimal pain. This is typical for the initial presentation of mild cellulitis.

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Mild cellulitis with a fine lacelike pattern of e...

Mild cellulitis with a fine lacelike pattern of erythema. This lesion was only slightly warm and caused minimal pain. This is typical for the initial presentation of mild cellulitis.


  • Hallmarks of cellulitis include the following:
    • Warmth, erythema, edema, and tenderness of the affected area are present.
      • Regional lymphadenopathy may be present.
      • The margin of cellulitis is not palpable. A disease similar to cellulitis, but with a sharply defined, palpable margin is erysipelas.
      • Fever may be present.
    • Cellulitis characterized by violaceous color and bullae suggests infection with Streptococcus pneumoniae (pneumococcus).
    • Associated red streaking visible in the skin proximal to the area of cellulitis is characteristic of ascending lymphangitis. In lymphangitis, the infection is carried through the lymphatic system.
  • Cellulitis with abscess formation:
    • Cellulitis was classically considered to be infection of the skin and subcutaneous tissues manifesting as warmth, tenderness, erythema, and edema without formation of abscess and without exhibiting purulent drainage or ulceration.
    • In clinical practice, the division between cellulitis and abscess is not distinct. Frequently, the macular erythema of cellulitis coexists with nodules, areas of ulceration, and frank abscess formation.

Causes

  • Bacterial and fungal infections
    • In individuals with normal host defenses, the most common causative organisms are group A streptococci and Staphylococcus aureus.
    • Cellulitis in neonates may present as sepsis, most commonly caused by group B streptococci.11
    • In immunocompromised hosts, gram-negative rods or fungi may cause cellulitis, though fungal cellulitis is rare.
    • Wounds occurring after exposure to fresh water may be caused by Aeromonas hydrophila, a gram-negative rod.12
    • Pneumococcus may cause a particularly malignant form of cellulitis, typically in an immunocompromised host, and frequently is associated with tissue necrosis, suppuration, and bloodstream invasion. Two distinct syndromes are recognized: one, marked by involvement of the extremities in patients with diabetes or substance abuse; and one, marked by involvement of the head, neck, and upper torso in patients with systemic lupus erythematosus, nephrotic syndrome, or hematologic disorders.13
  • Recurrent lower extremity cellulitis
    • A relationship was identified between the following risk factors and recurrent lower extremity cellulitis in a study of US Veterans Affairs Medical Center patients: increasing body mass indices, lower extremity edema, cigarette smoking, and homelessness.10
  • Facial cellulitis
    • Facial cellulitis is frequently associated with Haemophilus influenzae type B and Streptococcus pneumoniae.
    • A study of one half million pediatric hospitalizations demonstrated that, while bacterial meningitis and epiglottitis diminished as a result of immunization for H influenzae type B and S pneumoniae, the incidence of facial cellulitis was unaffected.14
  • Bullous cellulitis associated with cirrhosis15
    • Bullous cellulitis in patients with cirrhosis may be caused by gram-negative bacteria.
    • Gram stain and culture of fluid aspirated from the bullae may aid in management.
    • Early recognition is vital as the course of the disease is rapid, typically progressing to septic shock and death.
  • Patients with the following conditions are at increased risk of developing serious or rapidly spreading cellulitis:
    • Diabetes
    • Immunodeficiency
    • Other systemic illness
    • Varicella
    • Impaired peripheral circulation (arterial insufficiency or venous stasis)
    • Lymphadenectomy following tumor excision, such as mastectomy
    • Postvenectomy status following saphenous vein stripping:16 This is associated with the presence of tinea pedis. Culture of toe web spaces may assist in identifying a bacterial pathogen.17
  • Chronic steroid use increases the risk of cellulitis.
  • Cellulitis may complicate varicella.
    • Cellulitis may be identified by a margin of erythema surrounding the vesicles.
    • In one study, patients with invasive group A streptococcal (GAS) cellulitis complicating varicella were identified. The median onset of GAS infection was day 4 of varicella, with fever, vomiting, and localized swelling being reported.18
    • The development of cellulitis complicating varicella mandates antibiotic treatment and careful clinical follow-up. Untreated cellulitis in association with varicella may progress to severe necrotizing soft tissue infections requiring surgical intervention.19
  • Cellulitis associated with abscess formation and the association of cellulitis and methicillin-resistant Staphylococcus aureus (MRSA)
    • Cellulitis may be complicated by abscess formation. A maxim in microbiology states "the hallmark of staph infection is abscess formation." This has become a significant concern due to changing patterns of antibiotic resistance in Staphylococcus aureus.20
    • S aureus resistant to methicillin (called methicillin-resistant Staphylococcus aureus, or MRSA) was first reported in 1968.21 For some time, MRSA infections were identified only in patients with recent hospitalization, surgery, renal dialysis, residence in long-term-care facilities, or intravenous drug use.
    • More recently, isolates of S aureus have been found in patients without risk factors for nosocomial disease. These isolates have been termed community-associated methicillin resistant S aureus (CA-MRSA) to distinguish them from the previously identified hospital or healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA).22
    • Recent reports have indicated that MRSA causes the majority of skin and soft tissue infections. These studies are plagued by variability in case-finding methodologies.23 Further, in the context of cellulitis, this is misleading in that these reports come from analysis of wound cultures in cases where abscess formation occurred. Cultures in cellulitis are difficult to perform and are infrequently done. Therefore, the results of these studies cannot be generalized to cellulitis without abscess formation.
    • Studies are underway to determine the incidence of S aureus, and, in particular, CA-MRSA, in soft tissue infection in which there is no identifiable abscess. However, until results of those studies are available, treatment decisions must be made on clinical grounds. 
    • In practice, even in areas where CA-MRSA is prevalent, cellulitis continues to respond to usual antibiotics. Therefore, there is no reason at this time to recommend change in treatment protocols of cellulitis, in the absence of abscess formation, due to concerns about MRSA.24
  • Mycobacteria in immunocompromised host
    • Mycobacteria infections may present as cellulitis in an immunocompromised host (chronic disease such as systemic lupus erythematosus, steroid use). Typically, the lack of response to antibiotics prompts further investigation. Diagnosis is made based on presence of granulomas, multinucleated giant cells, and acid-fast bacilli on biopsy.25,26,27
  • Wounds sustained in an aquatic environment28
    • Lacerations and puncture wounds sustained in oceans, lakes, and streams may be contaminated with bacteria not typically found in land-based injuries.
    • Organisms found in these injuries include Aeromonas hydrophila, Pseudomonas and Plesiomonas species, Vibrio species, Erysipelothrix rhusiopathiae, Mycobacterium marinum, and others.
    • Antibiotic treatment should address common gram-positive and gram-negative aquatic organisms.
    • Appropriate antibiotic regimens for salt water or brackish water include doxycycline and ceftazidime, or a fluoroquinolone.
    • Appropriate regimens for injuries sustained in fresh water include a third- or fourth-generation cephalosporin (eg, ceftazidime or cefepime) or a fluoroquinolone (eg, ciprofloxacin or levofloxacin.)

More on Cellulitis

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

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Keywords

cellulitis, cellulitis infection, cellulitis treatment, cellulitis symptoms, inflammation of skin, skin infection, group A streptococci, Staphylococcus aureus, S aureus, group B streptococci, fungal cellulitis, erythema, Escherichia coli cellulitis, E colicellulitis, gas gangrene, perianal cellulitis, facial cellulitis, lymphangitis, MRSA, methicillin-resistant Staphylococcus aureus, staph infection

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Contributor Information and Disclosures

Author

Danny Lee Curtis, MD, Clinical Assistant Professor of Medicine, University of South Florida School of Medicine; Consulting Staff, James A. Haley Veterans' Hospital, Tampa, Florida
Danny Lee Curtis, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Mark Louden, MD, FACEP, Assistant Medical Director, Emergency Department, Duke Raleigh Hospital
Mark Louden, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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