eMedicine Specialties > Emergency Medicine > Infectious Diseases

Erysipelas

Geofrey Nochimson, MD, Consulting Staff, Department of Emergency Medicine, Sentara Careplex Hospital

Updated: Sep 24, 2008

Introduction

Background

Erysipelas is a skin infection typically caused by group A beta-hemolytic streptococci, although other streptococcal groups are occasionally causative agents. Infection involves the dermis and lymphatics and is a more superficial subcutaneous infection of the skin than cellulitis. Erysipelas is characterized by intense erythema, induration, and a sharply demarcated border, which differentiates it from other skin infections.

For a CME activity, see Invasive Group A Streptococcal Disease in Nursing Homes, Minnesota, 1995-2006.

Pathophysiology

The skin is the primary organ system affected.

Frequency

United States

Increasing incidence has been noted since the late 1980s.

Mortality/Morbidity

Erysipelas generally is benign; however, it can be fatal when associated with bacteremia in very young, elderly, or immunocompromised patients. The mortality rate is less than 1% in treated cases.

Sex

Slight female predominance is observed.

Age

Infection occurs at extremes of age, but erysipelas is primarily a disease of adults.

Clinical

History

• Erysipelas is a febrile illness with dermatological findings, characterized by an abrupt onset of illness with initial fever and chills followed by a painful rash occurring 1-2 days later.
• Muscle and joint pain may accompany illness.
• Nausea may be present.
• Headache and other systemic manifestations of an infectious process may occur.
• Skin discomfort is noted.

Physical

• The patient may appear healthy or toxic depending on the extent of infection.
• Fever is common.
• Dermatologic signs
  • Painful, erythematous, and edematous rash
  • Sharply-raised border with abrupt demarcation from healthy adjacent skin
  • Condition found in lower extremities in 70-80% of patients; face affected in 5-20% of patients
• Erythema is irregular with extensions that may follow lymphatic channels (lymphangitis).
  • Desquamation
  • Vesicles
  • Lymphadenopathy

Causes

• Group A streptococci are the most common cause. Less common etiologies include group G, C, and B streptococci and, rarely, staphylococci.
• A defect in skin barrier allows the infection to occur. Infection may occur after trauma, abrasions, skin ulcers, insect bites, eczema, and psoriatic lesions.
• Other predisposing factors
  • Lymphatic obstruction or edema
  • Saphenous vein grafting in lower extremities
  • Status postradical mastectomy
  • Immunocompromised patients, including patients who are diabetic or alcoholic
  • Arteriovenous insufficiency
  • Paretic limbs

Differential Diagnoses

Other Problems to Be Considered

Angioneurotic edema
Dermatophytid
Erysipeloid
Polychondritis
Scarlet fever
Tuberculoid leprosy

Workup

Laboratory Studies

• In general, diagnosis of erysipelas is made clinically. Few laboratory tests are of help in the ED.
• Complete blood count (CBC): Increased WBC with a leftward shift may be observed but is not specific for the diagnosis.
• Blood cultures
  • Positive in only 5% of cases
  • May be helpful when a question of the diagnosis or concern about bacteremia with metastatic infection exists
  • May be of some benefit in patients with prosthetic heart valves or other intravascular devices, artificial joints, or in the immunocompromised or toxic-appearing patient
  • Gram stain and culture of rash generally not helpful
• Antistreptolysin (ASO), streptozyme, and anti-DNAase titers may be helpful.

Treatment

Emergency Department Care

• Prompt treatment of erysipelas in the ED is crucial because of potentially rapid progression.
  • Symptomatic treatment of aches and fever
  • Hydration (oral intake if possible)
  • Cold compresses

Consultations

Primary care physician or infectious disease consultation may be appropriate in complex cases with serious underlying disease or in cases requiring admission. Dermatology consultation may be helpful if diagnosis is unclear.

Medication

Antibiotics should be started as soon as possible. In addition, antipyretic and analgesics may help alleviate symptoms.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible microorganisms, including streptococci. DOC as streptococcal resistance very rarely has been reported in those strains likely to cause erysipelas. Resistance not yet observed in group A strains.

Dosing

Adult

600,000-2,000,000 U/kg IV divided q6h

Pediatric

50,000-250,000 U/kg IV divided q4h

Interactions

Probenecid may increase penicillin effectiveness by decreasing its clearance; coadministration of tetracyclines may decrease penicillin effectiveness

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution with impaired renal function

Erythromycin (EES, E-Mycin, Ery-Tab)

Inhibits RNA-dependent protein synthesis, possibly by stimulating the dissociation of peptidyl t-RNA from ribosomes; arrests bacterial growth.
Indicated to treat infections caused by streptococci in penicillin-allergic patients.

Dosing

Adult

Mild cases: 250-500 mg PO qid
Severe cases: 500 mg IV q4-6h

Pediatric

Mild cases: 30-50 mg/kg/d PO qid
Severe cases: 50 mg/kg/d IV q6h

Interactions

Theophylline, digoxin, carbamazepine, and cyclosporine toxicity may increase when coadministered with erythromycin; also may potentiate the anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Use with caution in patients with liver disease; estolate preparation of erythromycin may cause cholestatic jaundice; GI adverse effects are common, thus doses should be given after meals; discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; consider clarithromycin or azithromycin for less GI upset, and for easier dosing

Penicillin VK (Veetids)

Used in mild cases. It inhibits biosynthesis of cell wall mucopeptides and is effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.

Dosing

Adult

250-500 mg PO qid

Pediatric

25-50 mg/kg/d PO divided qid

Interactions

Probenecid may increase penicillin effectiveness by decreasing its clearance; coadministration of tetracyclines may decrease the effect of penicillin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution with impaired renal function

Cephalexin (Keflex, Biocef)

First-generation cephalosporin that inhibits bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.
Acceptable alternative to penicillin and may be useful in patients with minor penicillin allergies.

Dosing

Adult

250-500 mg PO qid

Pediatric

25-50 mg/kg/d PO divided q6h

Interactions

Aminoglycosides increase nephrotoxic potential of cephalexin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment

Analgesics-antipyretics

Pain control is essential to quality patient care. These drugs ensure patient comfort, promote pulmonary toilet, and have sedating properties beneficial to patients who have sustained trauma or who experience pain.

Acetaminophen (Tylenol, Panadol, Aspirin Free Anacin)

DOC for treating pain in patients with documented hypersensitivity to aspirin or other NSAIDs, who are diagnosed with upper GI disease, or who take oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses q24h

Interactions

Rifampin may interact to reduce the analgesic effects of acetaminophen; conversely, barbiturates, carbamazepine, hydantoins, and isoniazid may increase acetaminophen hepatotoxicity

Contraindications

Documented hypersensitivity; G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in persons with chronic alcoholism following various dose levels of acetaminophen

Acetaminophen and codeine (Tylenol 3)

For treatment of mild to moderate pain.

Dosing

Adult

30-60 mg (based on codeine content) PO q4-6h or 1-2 tab PO q4h; not to exceed 12 tab q24h

Pediatric

Based on codeine: 0.5-1 mg/kg/dose PO q4-6h prn; not to exceed 5 doses q24h

Interactions

Increased toxicity with coadministration of CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Administer with caution in opiate-dependent patients because this substitution may result in acute opiate withdrawal symptoms; exercise caution when patients have severe renal or hepatic dysfunction

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

For relief of moderate to severe pain.

Dosing

Adult

1-2 tab/cap PO q4-6h prn pain

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen or 5 mg of hydrocodone bitartrate/dose
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose

Interactions

Phenothiazines may decrease its analgesic effects; toxicity increases with coadministration of CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity; elevated intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause allergic reactions; administer with caution in opiate-dependent patients because this substitution may result in acute opiate withdrawal symptoms; exercise caution in severe renal or hepatic dysfunction

Oxycodone and acetaminophen (Percocet)

For relief of moderate to severe pain. DOC for aspirin-hypersensitive patients.

Dosing

Adult

1-2 tab or cap PO q4-6h prn pain

Pediatric

0.05-0.15 mg/kg PO oxycodone; not to exceed 5 mg of oxycodone q4-6h prn

Interactions

Phenothiazines may decrease analgesic effects; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen; the maximum dose of acetaminophen is 4000 mg/d; higher doses may cause liver toxicity

Aspirin (Anacin, Ascriptin, Bayer Aspirin)

Blocks prostaglandin synthetase action, which in turn inhibits prostaglandin synthesis and prevents formation of platelet-aggregating thromboxane A₂; acts on hypothalamic heat-regulating center to reduce fever.

Dosing

Adult

325-650 mg PO q4-6h; not to exceed 4 g/d

Pediatric

10-15 mg/kg PO q4-6h; not to exceed 60-80 mg/kg/d

Interactions

Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs

Contraindications

Documented hypersensitivity; liver damage, hypoprothrombinemia, vitamin K deficiency, bleeding disorders, asthma; due to association of aspirin with Reye syndrome, do not use in children (<16 y) with flu

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants

Ibuprofen (Ibuprin, Advil, Motrin)

Usually the DOC for treating mild to moderate pain, if no contraindications exist. One of the few NSAIDs indicated for reduction of fever.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Follow-up

Further Outpatient Care

• Patients with erysipelas should have a follow-up visit with primary care 24-48 hours after ED visit, unless symptoms are clearly improving and other problems have not developed.

Inpatient & Outpatient Medications

• Antibiotics
• Analgesics
• Antipyretics

Complications

Complications of erysipelas may include the following:

• Gangrene/amputation
• Bacteremia sepsis
• Scarlet fever
• Pneumonia
• Abscess
• Embolism
• Meningitis
• Death

Prognosis

• Excellent, if treated properly in patients with intact immune systems
• Chronic edema
• Scarring
• Elephantiasis from chronic, recurrent cases (rare)
• May resolve spontaneously, even when untreated

Patient Education

• Instruct patients to rest, elevate affected area, and use warm compresses 4 times a day for 48 hours. Patients should return or see primary care physician if experiencing an increase in pain, fever and chills, redness, or other new symptoms.

Miscellaneous

Medicolegal Pitfalls

• Erysipelas may lead to serious morbidity and even mortality; therefore, for the clinician to recognize this illness and begin timely, appropriate treatment, and ensure necessary follow-up is critical.
• Appropriate antibiotics should be initiated as soon as possible; ensure patient has means to obtain antibiotics once discharged from ED.

Special Concerns

• Hospitalization recommended in patients who are toxic, have severe disease with immunocompromise, or are unlikely to complete course of treatment for psychosocial or economic reasons
• Significant underlying diseases
• Extremes of age

References

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

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

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

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

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

6. Jorup-Ronstrom C, Britton S. Recurrent erysipelas: predisposing factors and costs of prophylaxis. Infection. Mar-Apr 1987;15(2):105-6. [Medline].

7. 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].

8. Swartz MN. Erysipelas. In: Mandell GL, ed, et al. Principles and Practice of Infectious Diseases. 4^th ed. Churchill Livingstone; 1995:913-14.

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

10. Lopez FA, Lartchenko S. Skin and soft tissue infections. Infect Dis Clin North Am. Dec 2006;20(4):759-72, v-vi. [Medline].

11. Morris A. Cellulitis and erysipelas. Clin Evid. Jun 2006;2207-11. [Medline].

Keywords

erysipelas, group A beta-hemolytic streptococci, hemolytic streptococcus, skin infection, painful rash, erythematous rash, edematous rash, abrasions, skin ulcers, insect bites, eczema, psoriatic lesions, lymphatic obstruction, lymphatic edema, saphenous vein grafting in lower extremities, postradical mastectomy, immunocompromised patients, diabetes, alcoholism, arteriovenous insufficiency, paretic limbs

Contributor Information and Disclosures

Author

Geofrey Nochimson, MD, Consulting Staff, Department of Emergency Medicine, Sentara Careplex Hospital
Geofrey Nochimson, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

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, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

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