Erysipelas and Cellulitis

Patients typically present with a sudden onset of a painful, swollen, warm area of skin, often on the lower limbs, face, or hands. This may be accompanied by systemic symptoms such as fever, chills, and malaise. A history of skin trauma, ulcers, insect bites, or underlying conditions like tinea pedis or eczema is common. Risk factors include diabetes mellitus, venous insufficiency, lymphoedema, obesity, and immunosuppression.

Crucial Note for Darker Skin Tones:
Redness (erythema) may not be visible. Instead, the affected area may appear violaceous, greyish, or simply darker than the surrounding skin. Diagnosis often relies more heavily on tactile symptoms—warmth, induration (hardening), and tenderness—than on visual redness.

Examination differentiates between the two conditions based on depth and border definition. In all cases, mark the edge of swelling to monitor progression.

Erysipelas (Superficial):
Affects the upper dermis and lymphatics. Look for a well-demarcated, raised edge. On lighter skin, it appears bright red and shiny; on skin of colour, it may appear dusky, violaceous, or simply swollen with a "peel-like" sheen. It often presents in a butterfly distribution on the face or on the legs.

Cellulitis (Deep):
Affects the deeper dermis and subcutaneous tissue. Borders are ill-defined and diffuse. The skin appears warm, tense, and oedematous, potentially with a peau d’orange (orange peel) texture.

Complications:
Be vigilant for abscess formation, necrotising fasciitis, or cavernous sinus thrombosis (in facial cases). Post-inflammatory hyperpigmentation is common in darker skin tones and may persist for months after the infection clears.

General Measures:
Rest and limb elevation are critical to reduce oedema. Apply cool compresses and moist antiseptic dressings. Treat underlying portals of entry (e.g., tinea pedis between toes).

Antibiotics (First-line):

• Penicillin/Flucloxacillin (Oral or IV): The standard treatment for 10–14 days.

• Alternatives (for Penicillin Allergy): Erythromycin, roxithromycin, clindamycin, or doxycycline.

Broad Spectrum (MRSA/Polymicrobial):

• Combination Therapy: Agents such as Amoxicillin-clavulanate, TMP-SMX, or Vancomycin are required if MRSA is suspected or the infection is severe.

Severe Cases:

Hospitalisation: Required for systemic toxicity, failure of oral antibiotics, or extensive involvement. IV antibiotics and surgical drainage may be necessary if abscesses form.

Preventive Measures: Manage predisposing conditions like eczema and fungal infections aggressively. Maintain strict glycaemic control in diabetics. For recurrent cases, long-term low-dose prophylactic antibiotics (e.g., penicillin) may be considered.

General Measures: Rest and limb elevation are critical to reduce oedema. Apply cool compresses and moist antiseptic dressings. Treat underlying portals of entry (e.g., tinea pedis between toes).

Antibiotics (First-line):

• Penicillin/Flucloxacillin (Oral or IV): The standard treatment for 10–14 days.

• Alternatives (for Penicillin Allergy): Erythromycin, roxithromycin, clindamycin, or doxycycline.

Broad Spectrum (MRSA/Polymicrobial):

• Combination Therapy: Agents such as Amoxicillin-clavulanate, TMP-SMX, or Vancomycin are required if MRSA is suspected or the infection is severe.

Severe Cases:

Hospitalisation: Required for systemic toxicity, failure of oral antibiotics, or extensive involvement. IV antibiotics and surgical drainage may be necessary if abscesses form.

Preventive Measures: Manage predisposing conditions like eczema and fungal infections aggressively. Maintain strict glycaemic control in diabetics. For recurrent cases, long-term low-dose prophylactic antibiotics (e.g., penicillin) may be considered.