11.11 Erysipelas, Cellulitis and Lymphangitis

agk’s Library of Common Simple Emergencies

Presentation

The cardinal signs of infection (pain, redness, warmth, and swelling) are present. Erysipelas is very superficial and bright red with indurated, sharply demarcated borders. Cellulitis is deeper, involves the subcutaneous connective tissue, and has an indistinct advancing border. Lymphangitis has minimal induration and an unmistakable linear pattern ascending along lymphatic channels. These superficial skin infections are often preceded by minor trauma or the presence of a foreign body, and are most common in patients who have predisposing factors such as diabetes, arterial or venous insufficiency, and lymphatic drainage obstruction. They may be associated with an abscess or they may have no clear-cut origin. With any of these skin infections the patient may have tender lymphadenopathy proximal to the site of infection and may or may not have signs of systemic toxicity (fever, rigors, and listlessness).

What to do:

• Look for a possible source of infection and remove it. Debride and cleanse any wound, remove any foreign body or drain any abscess.
• When the patient is very sick, or there is discoloration of the entire limb, get medical consultation and prepare for hospitalization. Obtain a CBC and blood cultures and get x rays to look for gas-forming organisms. Hospitalization should also be strongly considered when deep facial cellulitis is present or the patient has a deep i,nfection of the hand.
• If there is low-grade fever, or none at all, you can usually treat on an outpatient basis. Prescribe dicloxacillin 500mg qid x 10d, cephalexin 500mg tid x 10d or cefadroxil lgm qd x 10d. Instruct the patient to keep the infected part at rest and elevated and to use intermittent warm moist compresses.
• Followup within 24-48 hours to insure that the therapy has been adequate. Infections still worsening after 48 hours of outpatient treatment may require hospital admission for better immobilization, elevation, and intravenous antibiotics.

Discussion

The most common etiologic agents are beta hemolytic streptococci or Staphylococcus aureus. Erysipelas and lymphangitis are often a result of Group A strep alone although S. aureus may produce a similar picture. H. influenzae should be considered in the toxic child with facial cellulitis. It may be easier to evaluate on followup whether a cellulitis is improving or not if the initial margin of redness, swelling, tenderness, or warmth was marked on the skin with a ball point pen. Because response to treatment is often equivocal at 24 hours, reevaluation is usually best scheduled at 48 hours.

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