Erysipelas

Erysipelas is an acute, superficial infection of the upper dermis and lymphatics, most often caused by S. pyogenes, occurring most commonly on the face and lower extremities. It differs from ordinary cellulitis by its raised, sharply demarcated border and prominent lymphatic involvement. Recurrence occurs in up to 30% of cases.^[1] Narrow anti-streptococcal therapy is the default; broad MRSA treatment is not routine.

Facial erysipelas — a raised, sharply demarcated erythematous plaque, distinguishing it from the diffuse border of ordinary cellulitis. (CDC/Dr. Thomas F. Sellers, Emory University — Public Health Image Library, public domain)

• Abrupt onset of painful, warm, edematous plaque.
• Raised, sharply defined edge rather than the diffuse border of cellulitis.
• Peau d'orange (orange-peel) texture may occur, from dimpling around hair follicles.
• Face and lower extremities are common sites.
• Bullae can complicate more severe disease and may require extended treatment duration.^[2]

• Broken skin and wounds.
• Chronic edema/lymphedema.
• Tinea pedis and interdigital fissures.
• Previous erysipelas/cellulitis.
• Venous disease, obesity, diabetes, or immunosuppression.

Diagnosis is clinical. Document the sharply defined raised edge, site, systemic symptoms, and portal of entry. Routine culture is usually not possible unless there is an open lesion. Blood cultures are reserved for severe/systemic cases. Evaluate recurrent lower-limb disease for edema and tinea pedis, both correctable risk factors.

• Rapidly control streptococcal infection.
• Resolve pain, edema, and systemic symptoms.
• Prevent deeper spread and recurrence.
• Correct portals of entry and chronic edema.

• Elevate the affected limb.
• Use cool compresses for comfort.
• Treat tinea pedis and skin fissures.
• Manage chronic edema with compression once the acute phase permits — daily compression stocking use reduces recurrence.^[3]
• Mark margins for objective follow-up.

Pregnancy

Penicillins and cephalosporins are preferred when the organism is susceptible. Clindamycin can be used for an appropriate severe beta-lactam allergy.

Recurrent lower-limb disease

Prioritize edema control, skin care, and treatment of interdigital fungal disease. Antibiotic prophylaxis is not first-line and should only be considered after recurrent episodes despite correction of modifiable risk factors.

Review within 48-72 hours. Border expansion should stop, pain and fever should improve, and edema should begin to recede. Bullous change or systemic deterioration requires escalation. Duration can be extended when clinical response is incomplete.

1. Confirm diagnosis and exclude cellulitis mimic.
2. Confirm beta-hemolytic streptococcal coverage and adherence.
3. Look for an occult abscess or deeper infection if purulence develops.
4. Reassess for necrotizing infection if pain/progression is severe.
5. Escalate to IV therapy or specialist care when response is inadequate.

• Using broad anti-MRSA therapy for classic uncomplicated erysipelas.
• Failing to distinguish a raised sharp border from diffuse cellulitis.
• Ignoring chronic edema and tinea pedis as correctable risk factors.
• Treating severe facial or bullous disease entirely as an outpatient.

How to use this table: Doses are adult doses and require patient-specific confirmation (renal/hepatic function, weight, allergy history). Pediatric dosing is weight-based per the current product monograph unless stated. Drug pricing is intentionally omitted. Select any drug name to open its complete Pharmasist Drug Database page.

Oral therapy (mild)

Parenteral therapy (severe)