11.11 Erysipelas, Cellulitis and Lymphangitis
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agk's Library of Common Simple Emergencies

Presentation
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The cardinal signs of infection (pain, redness, 
warmth, and swelling) are present. Erysipelas is 
very superficial and bright red with indurated, 
sharply demarcated borders. Cellulitis is deeper, 
involves the subcutaneous connective tissue, and 
has an indistinct advancing border. Lymphangitis 
has minimal induration and an unmistakable linear 
pattern ascending along lymphatic channels. These 
superficial skin infections are often preceded by 
minor trauma or the presence of a foreign body, 
and are most common in patients who have 
predisposing factors such as diabetes, arterial 
or venous insufficiency, and lymphatic drainage 
obstruction. They may be associated with an 
abscess or they may have no clear-cut origin. 
With any of these skin infections the patient may 
have tender lymphadenopathy proximal to the site 
of infection and may or may not have signs of 
systemic toxicity (fever, rigors, and 
listlessness).

What to do:
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- Look for a possible source of infection and 
    remove it. Debride and cleanse any wound, 
    remove any foreign body or drain any abscess.
- When the patient is very sick, or there is 
    discoloration of the entire limb, get medical 
    consultation and prepare for hospitalization. 
    Obtain a CBC and blood cultures and get x 
    rays to look for gas-forming organisms. 
    Hospitalization should also be strongly 
    considered when deep facial cellulitis is 
    present or the patient has a deep infection 
    of the hand.
- If there is low-grade fever, or none at all, 
    you can usually treat on an outpatient basis. 
    Prescribe dicloxacillin 500mg qid x 10d, 
    cephalexin 500mg tid x 10d or cefadroxil lgm 
    qd x 10d. Instruct the patient to keep the 
    infected part at rest and elevated and to use 
    intermittent warm moist compresses.
- Followup within 24-48 hours to insure that the 
    therapy has been adequate. Infections still 
    worsening after 48 hours of outpatient 
    treatment may require hospital admission for 
    better immobilization, elevation, and 
    intravenous antibiotics.

Discussion
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The most common etiologic agents are beta 
hemolytic streptococci or Staphylococcus aureus. 
Erysipelas and lymphangitis are often a result of 
Group A strep alone although S. aureus may 
produce a similar picture. H. influenzae should 
be considered in the toxic child with facial 
cellulitis. It may be easier to evaluate on 
followup whether a cellulitis is improving or not 
if the initial margin of redness, swelling, 
tenderness, or warmth was marked on the skin with 
a ball point pen. Because response to treatment 
is often equivocal at 24 hours, reevaluation is 
usually best scheduled at 48 hours.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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