INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Erysipelas is a skin infection typically caused by group A beta-hemolytic streptococci, although other streptococcal groups are occasionally causative agents. Infection involves the dermis and lymphatics and is a more superficial subcutaneous infection of the skin than cellulitis. Erysipelas is characterized by intense erythema, induration, and a sharply demarcated border, which differentiates it from other skin infections.

Pathophysiology

The skin is the primary organ system affected.

Frequency

United States

Increasing incidence has been noted since the late 1980s.

Mortality/Morbidity

Erysipelas generally is benign; however, it can be fatal when associated with bacteremia in very young, elderly, or immunocompromised patients. The mortality rate is less than 1% in treated cases.

Sex

Slight female predominance is observed.

Age

Infection occurs at extremes of age, but erysipelas is primarily a disease of adults.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Erysipelas is a febrile illness with dermatological findings, characterized by an abrupt onset of illness with initial fever and chills followed by a painful rash occurring 1-2 days later.
• Muscle and joint pain may accompany illness.
• Nausea may be present.
• Headache and other systemic manifestations of an infectious process may occur.
• Skin discomfort is noted.

Physical

• The patient may appear healthy or toxic depending on the extent of infection.
• Fever is common.
• Dermatologic signs
• • Painful, erythematous, and edematous rash
  • Sharply-raised border with abrupt demarcation from healthy adjacent skin
  • Condition found in lower extremities in 70-80% of patients; face affected in 5-20% of patients
• Erythema is irregular with extensions that may follow lymphatic channels (lymphangitis).
• • Desquamation
  • Vesicles
  • Lymphadenopathy

Causes

• Group A streptococci are the most common cause. Less common etiologies include group G, C, and B streptococci and, rarely, staphylococci.
• A defect in skin barrier allows the infection to occur. Infection may occur after trauma, abrasions, skin ulcers, insect bites, eczema, and psoriatic lesions.
• Other predisposing factors
• • Lymphatic obstruction or edema
  • Saphenous vein grafting in lower extremities
  • Status postradical mastectomy
  • Immunocompromised patients, including patients who are diabetic or alcoholic
  • Arteriovenous insufficiency
  • Paretic limbs

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Angioneurotic edema
Dermatophytid
Erysipeloid
Polychondritis
Scarlet fever
Tuberculoid leprosy

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• In general, diagnosis of erysipelas is made clinically. Few laboratory tests are of help in the ED.
• Complete blood count (CBC): Increased WBC with a leftward shift may be observed but is not specific for the diagnosis.
• Blood cultures
• • Positive in only 5% of cases
  • May be helpful when a question of the diagnosis or concern about bacteremia with metastatic infection exists
  • May be of some benefit in patients with prosthetic heart valves or other intravascular devices, artificial joints, or in the immunocompromised or toxic-appearing patient
  • Gram stain and culture of rash generally not helpful
• Antistreptolysin (ASO), streptozyme, and anti-DNAase titers may be helpful.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

• Prompt treatment in ED is crucial because of potentially rapid progression.
• • Symptomatic treatment of aches and fever
  • Hydration (oral intake if possible)
  • Cold compresses

Consultations

Primary care physician or infectious disease consultation may be appropriate in complex cases with serious underlying disease or in cases requiring admission. Dermatology consultation may be helpful if diagnosis is unclear.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Antibiotics should be started as soon as possible. In addition, antipyretic and analgesics may help alleviate symptoms.

Drug Category: Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Drug Category: Analgesics-antipyretics

Pain control is essential to quality patient care. These drugs ensure patient comfort, promote pulmonary toilet, and have sedating properties beneficial to patients who have sustained trauma or who experience pain.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Patients should have a follow-up visit with primary care 24-48 hours after ED visit, unless symptoms are clearly improving and other problems have not developed.

In/Out Patient Meds

• Antibiotics
• Analgesics
• Antipyretics

Complications

• Gangrene/amputation
• Bacteremia sepsis
• Scarlet fever
• Pneumonia
• Abscess
• Embolism
• Meningitis
• Death

Prognosis

• Excellent, if treated properly in patients with intact immune systems
• Chronic edema
• Scarring
• Elephantiasis from chronic, recurrent cases (rare)
• May resolve spontaneously, even when untreated

Patient Education

• Instruct patients to rest, elevate affected area, and use warm compresses 4 times a day for 48 hours. Patients should return or see primary care physician if experiencing an increase in pain, fever and chills, redness, or other new symptoms.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Erysipelas may lead to serious morbidity and even mortality; therefore, for the clinician to recognize this illness and begin timely, appropriate treatment, and ensure necessary follow-up is critical.
• Appropriate antibiotics should be initiated as soon as possible; ensure patient has means to obtain antibiotics once discharged from ED.

Special Concerns

• Hospitalization recommended in patients who are toxic, have severe disease with immunocompromise, or are unlikely to complete course of treatment for psychosocial or economic reasons
• Significant underlying diseases
• Extremes of age

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. Jan 25 1996;334(4):240-5. [Medline].
• Bonnetblanc JM, Bedane C. Erysipelas: recognition and management. Am J Clin Dermatol. 2003;4(3):157-63. [Medline].
• Bratten RL, Nesse RE. St. Anthony's Fire: Diagnosis and Management of Erysipelas. In: American Family Physician. Vol 51. 1995;401-04.
• Chartier C, Grosshans E. Erysipelas. Int J Dermatol. Sep 1990;29(7):459-67. [Medline].
• Elston DM. Epidemiology and prevention of skin and soft tissue infections. Cutis. May 2004;73(5 Suppl):3-7. [Medline].
• Jorup-Ronstrom C, Britton S. Recurrent erysipelas: predisposing factors and costs of prophylaxis. Infection. Mar-Apr 1987;15(2):105-6. [Medline].
• Krasagakis K, Samonis G, Maniatakis P. Bullous erysipelas: clinical presentation, staphylococcal involvement and methicillin resistance. Dermatology. 2006;212(1):31-5. [Medline].
• Swartz MN. Erysipelas. In: Mandell GL, et al. Principles and Practice of Infectious Diseases. 4th ed. Churchill Livingstone; 1995:913-14.
• Torok L. Uncommon manifestations of erysipelas. Clin Dermatol. Sep-Oct 2005;23(5):515-8. [Medline].

Article Last Updated: Jun 13, 2006