Erysipelas


Article Author:
Youstina Michael


Article Editor:
Nadia Shaukat


Editors In Chief:
Ahmad Al Aboud
Jayakar Thomas
Pramod Nigam


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Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
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Radia Jamil
Patrick Le
Sobhan Daneshfar
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Saad Nazir
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Pritesh Sheth
Hassam Zulfiqar
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Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/3/2019 12:36:24 PM

Introduction

Erysipelas is a skin infection involving the dermis layer of the skin, but it may also extend to the superficial cutaneous lymphatics. It is characterized by an area of erythema that is well demarcated, raised, and often affects the lower extremities, with the face being the second most commonly affected site. Erysipelas is also referred to “St. Anthony’s Fire” due to its intense fiery rash. Its diagnosis can overlap with cellulitis, and often a definite diagnosis cannot be made. Cellulitis has ill-defined borders and is slower to develop, while erysipelas has better-defined borders and faster development. Erysipelas can be serious but rarely fatal. It has a rapid and favorable response to antibiotics. Local complications are more common than systemic complication.

Etiology

The primary inciting infection involves streptococci. Most facial infections are due to Group A streptococcus while non-group A streptococcus involve more of the lower extremity. In a prospective study in Norway, researchers concluded that beta-hemolytic streptococci were the leading cause of facial cellulitis.[1] In neonates, Group B streptococcus is the leading cause of postpartum erysipelas. Erysipelas start with skin breaks and lead to the inoculation of the eliciting bacteria. Surgical incisions, insect bites, stasis ulcerations, and venous stasis are among the many entry portals. In addition, facial erysipelas may be caused by a recent infection in the nasopharynx passage.

Epidemiology

Most epidemiological studies on erysipelas have been done in different inpatient settings, across different countries. Erysipelas can affect people of all age groups, races, and sex. Some studies showed that erysipelas is more common in females. The incidence of erysipelas has decreased since the development of antibiotics and improved sanitation. Erysipelas can affect all age groups but is most common in the extremes of age.

Pathophysiology

Skin infection spreads through a break in the skin, directly invading the lymphatic system and causing erysipelas. Insect bites, stasis ulceration, surgical incisions, and venous insufficiency have been reported as portals of entry to the skin. Some risk factors that predispose people to develop erysipelas are obesity, lymphedema, athlete’s foot, leg ulcers, eczema, intravenous drug abuse, poorly controlled diabetes, and liver disease. Recurrent erysipelas has also been reported, with the infection typically reoccurring in the same site.

History and Physical

Erysipelas remains a clinical diagnosis, and assessing a patient for any recent skin trauma or pharyngitis is important. Patients often experience systemic symptoms, such as malaise, fever, and chills 48 hours before the onset of the skin lesion. It has been well described that erysipelas presents as an area of skin erythema that is sharply demarcated with raised edges. Often patients will complain of burning, tenderness, and itchiness at the site. The location of inflammation is very important. In lower extremity erysipelas, it is recommended to examine the interdigital toe spaces for fissures, scaling, or maceration.  Redness and swelling involving a joint should raise suspicion for other more serious disease processes like septic arthritis.

Evaluation

No laboratory workup is required for the diagnosis of erysipelas. Leukocytosis, elevated ESR and C-reactive protein are common but will not change the management or the treatment plan for most otherwise healthy individuals. Blood cultures have a low yield and are not routinely obtained; however, consider blood work and culture in the immunocompromised, ill-appearing patient. Also, consider extensive workup in patients who may be intravenous drug abusers, patients with prosthetic heart valves, and those with other intravascular devices. Patients who are septic will require full workup and resuscitation.

Treatment / Management

Antibiotics against streptococci should be initiated when erysipelas is suspected. Penicillin as monotherapy remains the first-line antibiotic used for the treatment of erysipelas. Coverage against MRSA is controversial. The 2014 Infectious Diseases Society of America (IDSA) guidelines for the diagnosis and management of skin and soft tissue infections[2] recommend coverage against methicillin-resistant Staphylococcus aureus (MRSA) in patients “whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS.”  Most patients with erysipelas can be discharged home on oral antibiotics. The recommended duration of antibiotic therapy is 5 days, but the period may be extended to 10 days if the infection does not improve. Hospitalization is recommended for concern of necrotizing infection, the immunocompromised, patients with poor adherence to medications and follow up, and for those whose outpatient treatment is failing.

A Cochrane review published in 2017, reviewed 5 trials assessing prevention of recurrent episodes of cellulitis and erysipelas. They concluded that patients who were on preventative treatment with antibiotics, particularly penicillin, had decrease risk of future episodes by 69%. In a retrospective study done in Prague,  they have found that Benzathine penicillin G 1.2 MU once every 3 weeks was effective prophylaxis for recurrent erysipelas; however, they could not conclude the needed appropriate duration of prophylaxis treatment.[3] The 2014 practice guidelines for the diagnosis and management of skin and soft tissue infections recommend oral penicillin or erythromycin twice a day for 4 to 52 weeks, or intramuscular benzathine penicillin every 2 to 4 weeks, in patients who have 3 to 4 episodes of cellulitis per year, despite attempts to treat or control predisposing factors.

Differential Diagnosis

There are diseases that can mimic erysipelas [4]; all of which present with erythema, warmth, edema, and pain. Some of the more serious diagnoses include septic bursitis, septic arthritis, necrotizing fasciitis, orbital cellulitis, deep vein thrombosis, phlegmasia cerulea dolens, flexor tenosynovitis, and toxic shock syndrome.  Less serious diagnoses include cellulitis, abscess, felon, gout, and paronychia.

Prognosis

Generally, the prognosis of erysipelas is good and can be managed in the outpatient setting. It responds well to oral antibiotics. However, extra caution should be taken in the immunocompromised and those with poor adherence to medication. Hospitalization for intravenous antibiotics is recommended in severe cases affecting those who are immunocompromised, infants, and the elderly. Close monitoring and observation are also recommended for those who will most likely not comply with instructions or complete their antibiotic course secondary to psychological or social reasons.

Complications

Complications of erysipelas can be serious but rarely fatal. Some local complications include abscess formation, skin necrosis, hemorrhagic purpura, and bullous formation. There has been a case report of erysipelas leading to bilateral lower limb and abdominal elephantiasis secondary to erysipelas.[5] A retrospective study of 152 cases of erysipelas evaluated for risk factors associated with local complications. They reported that prior empirical antibiotics and increased ESR at the time of admission were independent risk factors for the development of local complications of erysipelas.[6]

Enhancing Healthcare Team Outcomes

Erysipelas is commonly encountered by the primary care provider and nurse practitioner. The diagnosis in most cases is clinical but if there is any doubt, the patient should be referred to a dermatologist. The infection does respond to antibiotics and patients are usually managed as outpatients. Hospitalization is recommended for concern of necrotizing infection, the immunocompromised, patients with poor adherence to medications and follow up, and for those whose outpatient treatment is failing. The outcomes for patients with erysipelas are good as long as they remain compliant with antibiotic treatment.[7] (Level V)


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Erysipelas - Questions

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A patient develops a very painful swollen rash 48 hours after working in the garden. She has no other past history. Examination reveals a superficial skin lesion, mimicking cellulitis, that is extremely painful to palpation. The edges of the rash are sharp and raised. What is the most likely diagnosis?



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A pediatric patient who experienced chickenpox recently has been diagnosed with erysipelas or "St. Anthony's fire." Which of the following will most likely be prescribed?



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An otherwise healthy male presents with a history of athlete's foot complaining of the sudden onset of fever and pain in his right foot and leg and is found to have a well-defined red, indurated area on his right leg that appears to be progressing as well as inguinal lymphadenopathy. What is the most likely diagnosis in this case?



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Which of the following risk factors predispose to the development of erysipelas?



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Which of the following is the best treatment for erysipelas?



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What is standard therapy for an uncomplicated case of erysipelas?



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A 50 year old woman suddenly develops fever and erythematous swelling over the bridge of the nose that extends laterally beneath both eyes. The inflamed area is painful. The most likely diagnosis is:



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A 6-year-old boy who has recently recovered from an initial varicella zoster infection is diagnosed with erysipelas. Which of the following medications is indicated?



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What are the latest guidelines regarding prophylaxis treatment erysipelas?



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Which of the following may be a complication of erysipelas?



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Erysipelas - References

References

Rath E,Skrede S,Mylvaganam H,Bruun T, Aetiology and clinical features of facial cellulitis: a prospective study. Infectious diseases (London, England). 2018 Jan     [PubMed]
Blumberg G,Long B,Koyfman A, Clinical Mimics: An Emergency Medicine-Focused Review of Cellulitis Mimics. The Journal of emergency medicine. 2017 Oct     [PubMed]
Yang YP,Huang WX,Zhong WX,Fu YM,He PA,Zhao G,Feng QM, Bilateral Lower Limb and Abdominal Elephantiasis Due to Erysipelas. Chinese medical journal. 2018 Apr 5     [PubMed]
Titou H,Ebongo C,Bouati E,Boui M, Risk factors associated with local complications of erysipelas: a retrospective study of 152 cases. The Pan African medical journal. 2017     [PubMed]
Rob F,Hercogová J, Benzathine penicillin G once-every-3-week prophylaxis for recurrent erysipelas a retrospective study of 132 patients. The Journal of dermatological treatment. 2018 Feb     [PubMed]
Stevens DL,Bisno AL,Chambers HF,Dellinger EP,Goldstein EJ,Gorbach SL,Hirschmann JV,Kaplan SL,Montoya JG,Wade JC, Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014 Jul 15     [PubMed]
Dalal A,Eskin-Schwartz M,Mimouni D,Ray S,Days W,Hodak E,Leibovici L,Paul M, Interventions for the prevention of recurrent erysipelas and cellulitis. The Cochrane database of systematic reviews. 2017 Jun 20;     [PubMed]

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