Cellulitis and Erysipelas

Description

General Measures

Medicine Treatment

Referral

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L03.0-3/L03.8-9 + (L04.0-3/L04.8-9/B95.0-8) and A46

DESCRIPTION

These are skin and subcutaneous infections with pain, swelling, and erythema, usually caused by streptococci and staphylococci, and occasionally other organisms. Regional lymphadenitis may be present. Erysipelas has a raised demarcated border, whilst the border is indistinct in cellulitis.

The presence of areas of necrosis, haemorrhage, or pain out of proportion to the physical signs should raise suspicion of necrotising fasciitis which requires aggressive surgical debridement and broad-spectrum antibiotics (e.g. amoxicillin/clavulanic acid) as these infections are often polymicrobial.

GENERAL MEASURES

• Elevate the affected limb to reduce swelling and pain.
• Hydrate.

MEDICINE TREATMENT

Non-severe infection

Antibiotic therapy:

• Cefalexin, oral, 500 mg 6 hourly for 5 days

OR

• Flucloxacillin, oral, 500 mg 6 hourly for 5 days

LoE:IVbⁱⁱ

Severe penicillin allergy: (Z88.0)

• Macrolide, e.g.:
  • Azithromycin, oral, 500 mg daily for 3 days

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Note:

Severe cases may require parenteral antibiotics.

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Severe infection

The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period.

• Cefazolin, IV, 1 g 8 hourly

LoE:IIIbⁱⁱⁱ

When there is clinical improvement, change to:

• Flucloxacillin, oral, 500 mg 6 hourly

LoE:IIIb^iv

Severe penicillin allergy: (Z88.0)

• Clindamycin, IV, 600 mg 8 hourly

When there is clinical improvement, change to:

• Clindamycin, oral, 450 mg 8 hourly

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Note:

- If patients are treated with intravenous antibiotics, they should be switched to oral agents as soon as there is clinical improvement.
- Intravenous antibiotics are preferred in the setting of rapid progression of erythema.

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Pain control:

• NSAID, oral: e.g.
  • Ibuprofen, oral, 400 mg 8 hourly with meals

OR

• Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours)
• Maximum dose: 15 mg/kg/dose

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Note:

- If the patient is admitted and bed-bound with lower limb cellulitis, consider deep venous thrombosis prophylaxis (See Venous thrombo-embolism).
- If Tinea pedis is suspected to be the predisposing cause, treat accordingly. see Fungal infections.

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REFERRAL

Urgent

• For debridement if necrotising fasciitis is suspected, i.e. gangrene, gas in the tissues or haemorrhagic bullae.

Non-urgent

• To surgeon for non-response.
• For further investigation and potential biopsy if cellulitis is associated with wounds exposed to aquatic environments, (salt water, brackish water, or fresh water), or if there is a lack of response to treatment.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.0_07 November 2024

Chapter 4 Dermatology_4.2 Cellulitis and Erysipelas