Erysipelas Treatment & Management

Updated: Jun 19, 2020
  • Author: Loretta S Davis, MD; Chief Editor: William D James, MD  more...
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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.


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]  A 2020 review of three randomized controlled trials deemed empiric coverage for methicillin-resistant S aureus (MRSA) unnecessary for most patients and surmised these findings would likely apply to methicillin-susceptible S aureus (MSSA). However, this review reemphasized the need for additional studies comparing penicillin or amoxicillin monotherapy to those broader-spectrum antibiotics covering MSSA. [20]

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. [21]  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:



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



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.


Long-Term Monitoring

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. [22, 23] 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. [24] Oral penicillin or erythromycin twice daily for 4-52 weeks is an alternate regimen. [25]