Erysipelas Description: A specific, acute, superficial cutaneous cellulitis caused by hemolytic streptococci and characterized by hot, red, edematous, brawny, and sharply defined eruptions; usually accompanied by severe constitutional symptoms. Erysipelas is also known as ignis sacer (hell's fire) and St Anthony's fire. The incidence of erysipelas declined throughout the mid-20th century, possibly due to antibiotic development, improved sanitation, and decreased virulence. The change in distribution from the face to the lower extremities is most likely related to an aging population with risk factors such as lymphedema. Approximately 85% of cases occur on the legs rather than the face. Erysipelas is somewhat more common in European countries. Isolated cases are still the rule, and distribution and etiology remain similar to that in the United States. Erysipelas has been reported to be more common in females, but occurring at an earlier age in males because of their more aggressive activities. Other studies indicate that predisposing factors, rather than gender, account for any male/female differences in incidence. The most common complaints during the acute infection include tenderness of the involved area, fever, chills, and swelling. Death as a direct result of erysipelas is exceedingly rare. Predisposed patients often develop local recurrence, and this can lead to disfiguring and disabling healing reactions, such as elephantiasis nostras verrucosa. This chronic warty, edematous condition is caused by lymphatic destruction from repeated infection. Symptoms:Erysipelas The most obvious symptom of erysipelas is a red, swollen and warm skin lesion. It may be anywhere on the skin. However, many cases are on a patient's face, arms, fingers, legs or toes. Erysipelas most often affects the legs, eyes, ears and cheeks. The erysipelas skin lesion enlarges rapidly and has a clearly visible edge. It is often painful to the touch and may feel or look like orange skin. Severe lesions may blister, have broken capillaries or even lead to skin cells dying rapidly. The patient's lymph nodes may be swollen. In addition, a red streak from the affected area to the lymph node may appear. Other symptoms of erysipelas include a fever, shivering, chills, sudden tiredness and enlarged lymph glands. In extreme cases, a patient may have headaches or even vomit. People with erysipelas generally feel slightly or even very ill within 48 hours of the start of the infection. Causes and Risk factors: Streptococci are the primary cause of erysipelas. Most facial infections are attributed to group A streptococci, with an increasing percentage of lower extremity infections being caused by non-group A streptococci. Streptococcal toxins are thought to contribute to the brisk inflammation that is pathognomonic of this infection. No clear proof has emerged that other bacteria cause typical erysipelas, although they clearly coexist with streptococci at sites of inoculation. Recently, atypical forms reportedly have been caused by Streptococcus pneumoniae, Klebsiella pneumoniae, Haemophilus influenzae, Yersinia enterocolitica, and Moraxella species, and they should be considered in cases refractory to standard antibiotic therapy. The role of Staphylococcus aureus, and specifically methicillin-resistant S aureus, remains controversial. No conclusive evidence demonstrates a pathogenic role for staphylococci in typical erysipelas. The infection's predictable response to penicillin, even when S aureus is present, argues against S aureus as an etiologic agent. However, analogous to what occurs in bullous impetigo or staphylococcal scalded skin syndrome, exotoxins from coexisting S aureus may account for the clinical presentation of bullous erysipelas Risk factors include: A cut in the skin.
  • Problems with drainage through the veins or lymph system.
  • Skin sores (ulcers).
Diagnosis: Erysipelas is diagnosed mainly by the appearance of the rash. Blood tests and skin biopsies generally do not help make the diagnosis. In the past, saline solution was injected into the edge of the rash, aspirated back out, and cultured for bacteria. This method of diagnosis is not used anymore because bacteria were not found in the majority of cases. If the preceding symptoms such as fever and fatigue are significant enough, sometimes blood is drawn and cultured for bacteria to rule out sepsis. Treatment: Streptococci cause most cases of erysipelas; thus, penicillin has remained first-line therapy. Penicillin administered orally or intramuscularly is sufficient for most cases of classic erysipelas and should be given for 10-20 days.
  1. A cephalosporin or macrolide, such as erythromycin or azithromycin, may be used if the patient has an allergy to penicillin. Cephalosporins may cross-react with penicillin first-generation cephalosporins and should not be used in patients with a history of severe penicillin allergy, urticarial reactions, or anaphylaxis.
  2. Hospitalization for close monitoring and intravenous antibiotics is recommended in severe cases and in infants, elderly patients, and patients who are immunocompromised
  3. Two drugs, roxithromycin and pristinamycin, have been reported to be extremely effective in the treatment of erysipelas. Several studies have demonstrated greater efficacy and fewer adverse effects with these drugs compared with penicillin. Currently, the Food and Drug Administration has not approved these drugs in the United States, but they are in use in Europe.
Most patients with erysipelas respond very well to conventional antibiotic therapy. However, in atypical infections that are unresponsive to first- and second-line agents, an infectious disease consult may be useful. Medicine and medications: Erysipelas is treated with antibiotics. A variety of antibiotics can be used including penicillin, dicloxacillin, cephalosporins, clindamycin, and erythromycin. Most cases of erysipelas can be treated with oral antibiotics. However, cases of sepsis, or infections that do not improve with oral antibiotics require IV antibiotics administered in the hospital. DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.


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