Erysipelas

HPI:
A male toddler presents to the CED because mom is worried about a rash on his lower right leg.  She says it started all of sudden yesterday after he complained of getting bit by a bug.  Overnight it has become red, swollen, and hurts when it’s touched.  He’s had no fevers. 

Physical Exam:  
Afebrile and vital signs are all normal.  5cmx4cm area of raised erythema along the anterior lower right leg.  No fluctuance felt and no obvious pustules seen.  No drainage noted.  It is very painful to touch.

Work-up:

• History and clinical exam only
  

Management:
1.) Non-antibiotic therapy

• Elevation of affected area – gravity helps drain edema
  
• Avoid dry cracked skin 
  
• Consider compression if a degree of lymphedema present
  

2.) Antibiotics therapy
o Mild and immunocompetent host 

• Oral penicillin, amoxicillin, or cephalexin is first line
  
• Macrolides (especially erythromycin) are effective but resistance is increasing
  
• Clindamycin if pencillin/cephalosporin allergic
  
• Linezolid if clindamycin allergy as well
  
• Treat for 5-10 days typically
  

o Systemic infection, significant comorbidities (immunocompromised), or PO failure

• IV penicillin, cefazolin, or ceftriaxone
  
• Admit until okay to transition back to oral antibiotics
  

3.) Anticipatory guidance

• Follow-up within 24-48 hours or sooner if symptoms worsen
  
• Warn parents that erythema will likely worsen and that this does not mean treatment failure (antibiotic killing of pathogen = release of enzymes and local inflammation)
  

Discussion:

• Bimodal peak in young children and the elderly
  
• Increased risk with venous/lymphatic obstruction, trauma, diabetes, inflammation, preexisting skin infection, and insect bites
  
• Often secondary to Group A strep but sometimes Group B, C, or G strep as well
  
• Rarely secondary to staph aureus, klebsiella, yersinia, or haemphilus (if unimmunized)
  
• Typically an abrupt presentation but sometimes will have prodrome of fever, chills, and malaise 
  
• Characteristic rash – involves upper dermis and superficial lymphatics only, erythematous, raised, warm, shiny, tender, firm, and well demarcated from uninvolved skin
  
• Often effects the lower extremities and sometimes the face
  
• Burning pain = “St. Anthony’s Fire”
  
• Often confused with cellulitis which typically effects the deeper dermal layers
  
• Clinical diagnosis
  
• Blood cultures not routinely helpful in immunocompetent hosts – helpful in 0.6-5% of patients
  

By Jeremiah Smith, MD

References:

• Hescock, G, et al.  Visual Diagnosis: A Child Who Has a Worsening Rash.  Pediatrics in Review 2007;28:e1-e5
  
• Lawrence, H, Nopper, A.  (2012).  Superficial Bacterial Skin Infections and Cellulitis.  In S Long (editor), Principles and Practice of Pediatric Infectious Disease (pp. 427-435).  New York, NY:Elsevier
  
• Neri, I, et al.  Erysipelas as a Superinfection of an Oral Lymphangioma.   Journ of Pediatr 2014;165:205-206
  
• Trenchs, V, et al.  Blood Cultures are not Useful in the Evaluation of Children with Uncomplicated Superficial Skin and Soft Tissue Infections.  Pediatr Infect Dis J 2015;June:Epub ahead of print