ErysipelasMANAGEMENT

DERMATOLOGY PRESENTATIONS · 12 SECTIONS

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749 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Allergic contact dermatitis Bullous Pemphigoid Cutaneous Abscess DRESS syndrome Eczema Herpeticum Erysipelas Erythema multiforme Henoch-Schönlein purpura Herpes Zoster (Shingles)Herpetic Whitlow Hidradenitis suppurativa Paronychia Pediculosis (Lice)Pemphigus Vulgaris Pilonidal Abscess Pressure injury Psoriasis (acute flare)Psoriasis Flare Staphylococcal Scalded Skin Syndrome Stevens-Johnson Syndrome (SJS)Toxic Epidermal Necrolysis (TEN)Urticaria (acute)Warfarin-induced Skin Necrosis

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp51

Immediate priorities

›Hemodynamic and skin threat recognition

›Necrotizing fasciitis exclusion

›Pain out of proportion to exam findings

›Dusky or violaceous discoloration

›Skin necrosis or crepitus

›Sepsis screening

›Fever with tachycardia and hypotension

›MAP < 65 mmHg

›Altered mental status

›If necrotizing fasciitis suspected, emergent surgical consult without delay for imaging

›Class I recommendation

›Imaging should not delay operative exploration when clinical suspicion high

›Severity stratification

›SIRS criteria met

›Temperature > 38.3 C or < 36 C

›Heart rate > 90 per minute

›Respiratory rate > 20 per minute

›WBC > 12 or < 4 x10^9/L

›Rapid spread of erythema beyond marked borders

›Mark borders with skin marker on arrival

›Reassess within 24 to 48 hours

›Failure to improve after 48 to 72 hours of antibiotics

›Broaden differential and imaging

›Reassess antibiotic coverage

Monitoring and escalation

›Clinical monitoring bundle

›Skin border marking with timestamp

02History/hx75

Presentation pattern

›Core skin syndrome

›Acute onset well-demarcated painful erythema

›Rapid spread over hours to days

›Tongue-like extensions characteristic

›Constitutional symptoms preceding or accompanying skin findings

›Fever and chills

›Rigors and malaise

›91.4% of patients report constitutional symptoms at or before erythema onset

›Systemic symptoms may precede skin findings by hours

›Distinguishes from contact dermatitis

›Alarm symptoms

›Pain out of proportion to visible skin findings

›Necrotizing fasciitis exclusion required

›Cutaneous numbness or anesthesia

›Crepitus or skin necrosis

›Emergent surgical evaluation

›Do not delay for imaging

›Rapidly spreading erythema with bullae or violaceous discoloration

›High-risk feature

›Systemic toxicity assessment

Risk factors

›Cutaneous barrier disruption

›Disruption of skin barrier is strongest risk factor (OR 23.8)

›Leg ulcers and wounds

›Tinea pedis and toe-web intertrigo — population attributable risk 61% for leg erysipelas

›Chronic skin conditions

›Eczema and psoriasis

03Physical Exam/exam74

Vitals and general

›Hemodynamic stability assessment

›Temperature

›Fever present in 25 to 77% depending on setting

›Hypothermia as severe sepsis marker

›Heart rate

›Tachycardia > 100 per minute as severity marker

›Persistent tachycardia despite fluids is escalation trigger

›Blood pressure

›SBP < 90 mmHg suggests septic shock

›MAP < 65 mmHg

›Respiratory rate

›Elevated in sepsis

›General appearance

›Toxic appearance suggesting systemic infection

›Diaphoresis

›Pallor and agitation

›Altered mental status

›Sepsis encephalopathy consideration

›Baseline cognition comparison

Skin exam

›Classic erysipelas findings

›Sharply demarcated raised bright-red warm tender plaque

›Raised border distinguishing from deeper cellulitis

›Peau d'orange texture from lymphatic involvement

›Tongue-like extensions at advancing edge

›Characteristic of erysipelas

›Mark border with skin marker and timestamp

04Differential Diagnosis/ddx70

Life-threatening diagnoses

›Necrotizing fasciitis

›ICD-10 M72.6

›Rapidly spreading deep infection

›Mortality 20 to 40% overall

›Differentiating features

›Pain out of proportion

›Skin changes beyond erythema

›LRINEC score as adjunct

›Score >= 6 PPV 92% and NPV 96% for necrotizing fasciitis

›Septic shock from skin source

›ICD-10 A41.9

›Hypotension and organ dysfunction

›Mortality significantly elevated

›Streptococcal toxic shock syndrome

›GAS bacteremia with multiorgan failure

›Requires ICU management

Common mimics

›Cellulitis

›ICD-10 L03

›Poorly demarcated borders

›Involves deeper dermis and subcutaneous tissue

›Distinguishing from erysipelas

›Erysipelas has sharply raised well-demarcated borders

›May be clinically indistinguishable in practice

›Deep vein thrombosis

›ICD-10 I82

›Unilateral leg swelling and erythema

05Laboratory Tests/lt54

Core labs

›Infection and inflammation markers

›Complete blood count

›Leukocytosis expected

›WBC > 15.4 x10^9/L raises concern for necrotizing fasciitis

›C-reactive protein

›CRP >= 3.27 mg/dL distinguishes erysipelas from limited cellulitis

›Sensitivity 75% and specificity 73%

›Erythrocyte sedimentation rate

›Elevated in approximately 60% of erysipelas cases

›Less specific than CRP

›Metabolic panel

›Electrolytes and renal function

›Sodium < 135 mmol/L raises concern for necrotizing fasciitis

›Creatinine for antibiotic dosing adjustment

›Glucose

›Hyperglycemia indicates diabetes as comorbidity

›Stress hyperglycemia in severe infection

Necrotizing fasciitis exclusion labs

›LRINEC score components

›CRP

›>= 150 mg/L = 4 points

›WBC

›15 to 25 x10^9/L = 1 point

›> 25 x10^9/L = 2 points

›Hemoglobin

›11 to 13.5 g/dL = 1 point

›< 11 g/dL = 2 points

06Diagnostic Tests/dt69

Scoring Systems

›LRINEC score

›Laboratory Risk Indicator for Necrotizing Fasciitis

›Based on WBC, hemoglobin, sodium, glucose, creatinine, and CRP

›Score >= 6 PPV 92% and NPV 96% in index study

›Clinical use

›Adjunct to clinical judgment not a standalone rule-out

›Score >= 8 high risk category

›Clinical suspicion supersedes score

›Wells score for DVT

›Applies when unilateral leg swelling disproportionate to erythema

›Pooled DVT incidence in erysipelas approximately 2 to 3%

›Comparable to low-risk Wells patients

›Low Wells score plus negative D-dimer reasonable to exclude DVT

›Duplex ultrasound if Wells intermediate or high

›Erysipelas severity assessment

›No validated EM-specific scoring tool for erysipelas

›Clinical severity markers used in practice

›Admission criteria based on IDSA and expert consensus

MRI

›MRI soft tissue role

›Most sensitive modality for deep soft tissue infection

›Fascial thickening and signal change

›Fluid along fascial planes suggests necrotizing fasciitis

›Rarely needed acutely for erysipelas

›Use when diagnosis uncertain after CT

›Not for uncomplicated superficial erysipelas

›Indications

07Disposition/dispo43

Admission indications

›Criteria for inpatient management

›Systemic toxicity

›Fever > 38.5 C with tachycardia

›Hypotension SBP < 90 mmHg

›Failure of outpatient therapy

›No improvement after 48 to 72 hours of oral antibiotics

›Expanding erythema on oral therapy

›High-risk host

›Immunocompromised including chemotherapy or HIV

›Poorly controlled diabetes mellitus

›Location or severity

›Facial erysipelas near orbit

›Rapidly spreading infection requiring close monitoring

ICU indications

›Critical illness

›Septic shock requiring vasopressors

›MAP < 65 mmHg despite fluid resuscitation

›Norepinephrine initiation

›Suspected necrotizing fasciitis

›Emergent surgical evaluation

›Resuscitation while awaiting operative management

›Streptococcal toxic shock syndrome

›Multiorgan dysfunction

›High-dose penicillin plus clindamycin

Discharge criteria and follow-up

›Outpatient criteria

›Hemodynamically stable

08Treatment/t92

Non-antibiotic immediate measures

›Supportive measures

›Skin border marking

›Skin marker with time and date

›Document in chart

›Limb elevation

›Reduces edema and speeds resolution

›Elevation above heart level when feasible

›Entry portal treatment

›Treat tinea pedis with topical antifungal

›Wound care and dressing for ulcers

›Fluids and analgesia

›IV fluid resuscitation if septic

›30 mL/kg IV crystalloid for septic shock

›Reassess frequently

›Analgesia for pain

›Oral acetaminophen or NSAIDs

›IV analgesia for severe cases

Antibiotics — outpatient

›First-line outpatient therapy

›Penicillin V (phenoxymethylpenicillin) PO

›500 mg PO four times daily

›Response rate 98.3% within 2 days in uncomplicated cases

›Amoxicillin PO

›500 mg PO three times daily

›Alternative to penicillin V with equivalent efficacy

›Duration 5 days per IDSA guideline

›Extend if no clinical improvement

›Class I recommendation for 5-day course

›Penicillin allergy alternatives

›Cephalexin PO

›500 mg PO four times daily

›For non-anaphylactic penicillin allergy

›Clindamycin PO

›300 to 450 mg PO three times daily

›High C. difficile risk counseling required

›Azithromycin PO

›500 mg PO day 1 then 250 mg PO daily for 4 days

›Macrolide resistance increasingly reported

Antibiotics — inpatient

›First-line IV therapy

›Penicillin G IV

›2 to 4 million units IV every 4 to 6 hours

›Drug of choice for confirmed streptococcal erysipelas

›Cefazolin IV

›1 to 2 g IV every 8 hours

›Non-penicillin allergy alternative

›Renal adjustment required for penicillin G and cefazolin when creatinine elevated

›Dose frequency reduction

›Pharmacist review

›MRSA coverage indications

›MRSA coverage generally unnecessary for classic non-purulent erysipelas

›Add only if purulent drainage present

›Or penetrating trauma, IVDU, MRSA colonization, or SIRS

›Vancomycin IV when MRSA coverage required

›15 to 20 mg/kg IV every 8 to 12 hours

›AUC-guided monitoring per local protocol

›Linezolid IV or PO alternative

›600 mg every 12 hours

›Platelet monitoring with prolonged use

Antibiotics — necrotizing fasciitis protocol

›Empiric broad-spectrum coverage

›Piperacillin-tazobactam IV

›4.5 g IV every 6 hours

›Extended infusion per local protocol

›Plus vancomycin IV

›15 to 20 mg/kg IV every 8 to 12 hours

›For MRSA coverage

›Surgical debridement is primary treatment

›Antibiotics adjunct to surgery not substitute

›Class I recommendation for emergent surgical exploration

›Clostridial or mixed infection

›High-dose penicillin G plus clindamycin

›Penicillin G 4 million units IV every 4 hours

›Clindamycin 900 mg IV every 8 hours

›Clindamycin added for toxin suppression

›Inhibits ribosomal protein synthesis

›Reduces streptococcal toxin production

Prophylaxis for recurrent erysipelas

›Secondary prophylaxis indications

›Two or more episodes per year

›Strong indication for prophylaxis

›NNT = 6 to prevent one recurrence

›Prophylaxis reduces recurrence by approximately 69% while on therapy

›Benefits persist during treatment only

›Recurrence risk returns after cessation

›Prophylaxis regimens

›Penicillin V PO

›250 mg PO twice daily

›Preferred first-line prophylaxis

›Erythromycin PO

›250 mg PO twice daily

›For confirmed penicillin allergy

›Duration of prophylaxis

›Minimum 6 months

›Continue as long as risk factors present

›Consider indefinite if lymphedema or recurrent episodes

09Special Populations/sp82

Pregnancy

›Pregnancy-specific considerations

›Antibiotic safety

›Penicillin G and amoxicillin are safe in all trimesters

›Cephalexin and cefazolin acceptable

›Agents to avoid

›Tetracyclines contraindicated

›Fluoroquinolones generally avoided

›Clindamycin

›Considered safe in pregnancy for penicillin allergy

›Category B agent

›Monitoring in pregnancy

›Fetal monitoring when viable gestation in admitted patients

›Sepsis increases risk of preterm labor

›Obstetric consultation for systemic illness

›Imaging approach

›Clinical diagnosis preferred without radiation

›Ultrasound for abscess or DVT evaluation

›CT only when benefits outweigh radiation risks

›Systemic illness in pregnancy

›Lower threshold for admission

›Rapid progression risk

›Fetal compromise from maternal fever and sepsis

›Antipyretics to reduce fever

›Acetaminophen preferred

›NSAIDs avoid in third trimester

Geriatric

›Atypical presentations

›Fever may be absent despite significant infection

›Attenuated febrile response in older adults

›Occult sepsis risk

›Delirium as presenting feature

›May precede skin findings

›Baseline cognitive assessment required

›Functional decline

›Fall risk

›Mobility impact

›Medication considerations

›Renal dosing adjustments required

›eGFR-based dose modification

›Pharmacist consultation in complex cases

›Drug interactions

›Warfarin interaction with antibiotics

›INR monitoring if on anticoagulation

›Avoid fluoroquinolones when possible

›Tendon rupture risk

›C. difficile risk higher in older adults

›Disposition and support

›Lower threshold for admission in frail older adults

›Limited home supports

›Inability to reliably take oral medications

›Swallowing assessment if oral route uncertain

›IV route preferred in impaired swallow

›Pressure injury prevention

›Bed rest and immobility considerations

›Early mobilization planning

Pediatrics

›Clinical features in children

›Facial erysipelas more common in infants and young children

›Previously associated with H. influenzae type b before vaccination

›Group A Streptococcus dominant cause in vaccinated children

›Lower extremity involvement in older children similar to adults

›Trauma and skin breaks as entry portals

›Antibiotic dosing in children

›Amoxicillin PO for outpatient

›50 mg/kg/day divided every 8 hours

›Maximum 500 mg per dose

›Cephalexin PO alternative

›25 to 50 mg/kg/day divided every 6 hours

›Maximum 500 mg per dose

›Cefazolin IV for inpatient

›50 mg/kg/day IV divided every 8 hours

›Maximum 6 g per day

›Clindamycin PO or IV for penicillin allergy

›30 to 40 mg/kg/day divided every 6 to 8 hours

›Maximum 450 mg per dose

›Pediatric escalation thresholds

›Increased work of breathing as severity marker

›Lower threshold for respiratory compromise

›Feeding intolerance in infants and young children

›Inability to take oral antibiotics

›Consider IV therapy

›Rapid progression of erythema

›Pediatric infectious disease consultation

›Consider hospital admission more readily

10Background/b76

Epidemiology

›Frequency and distribution

›Common acute bacterial skin infection

›Annual incidence approximately 10 to 30 cases per 10000 population

›Increasing incidence with aging population

›Site distribution

›Lower extremities 76 to 85% of cases

›Face 17% of cases

›Demographics

›Any age group affected

›Higher prevalence in older adults and obese patients

›Recurrence burden

›Recurrence rate 8 to 20% annually

›Up to 40% lifetime recurrence rate

›Persistent predisposing risk factors drive recurrence

›Risk factors for recurrence

›Prior episode strongest predictor

›Lymphedema and venous insufficiency

›Obesity and diabetes

›Microbiology

›Group A Streptococcus (Streptococcus pyogenes) predominant pathogen

›Beta-hemolytic streptococci primary cause

›Groups B, C, and G streptococci also implicated

›Staphylococcus aureus

›Secondary role in non-purulent erysipelas

›MRSA uncommon in classic non-purulent presentation

Pathophysiology

›Infection mechanism

›Entry portal establishes bacterial inoculation

›Disrupted skin barrier allows beta-hemolytic streptococcal entry

›Tinea pedis accounts for 61% population attributable risk

›Superficial dermis and lymphatic infection

›Infection confined to upper dermis and superficial lymphatics

›Distinguishes from cellulitis which involves deeper dermis and subcutaneous tissue

›Inflammatory cascade

›Streptococcal toxins and immune activation

›Lymphatic obstruction from repeated episodes

›Lymphatic involvement

›Lymphangitis and regional lymphadenopathy

›Characteristic feature of erysipelas

›Contributes to peau d'orange appearance

›Recurrent infection causes progressive lymphatic damage

›Predisposing to further episodes

›Self-perpetuating cycle of lymphedema and infection

›Virulence factors

›M protein of Group A Streptococcus

›Antiphagocytic properties

›Immune evasion

›Streptococcal pyrogenic exotoxins

›Superantigen activity in severe cases

›Streptococcal toxic shock syndrome

Therapeutic Considerations

›Antibiotic choice rationale

›Penicillin remains gold standard

›Erysipelas is almost exclusively caused by penicillin-sensitive streptococci

›Response rate 98.3% within 2 days

›MRSA coverage not required for non-purulent erysipelas

›Reserve for purulent, IVDU-associated, or MRSA-colonized patients

›IDSA 2014 guideline Class I recommendation

›Topical antibiotics are ineffective

›Systemic therapy required

›Do not delay systemic treatment

›Recurrence prevention strategy

›Entry portal treatment is primary prevention

›Treat tinea pedis aggressively

›Manage chronic leg ulcers and edema

›Weight and edema management

›Compression stockings for venous insufficiency

›Weight loss counseling for obesity

›Secondary prophylaxis

›Penicillin V 250 mg PO twice daily reduces recurrence by 69%

›Consider in patients with >= 2 episodes per year

›Treatment failure assessment

›Failure within 48 to 72 hours warrants reassessment

›Necrotizing fasciitis exclusion

›Resistant organism or unusual pathogen

›IV-to-oral step-down when clinically improving

›Fever resolved

›Erythema stabilized or reducing

11Patient Discharge Instructions/pdi36

copy discharge instructions

›Erysipelas home care instructions

›Complete the full antibiotic course as prescribed

›Do not stop early even if feeling better

›Typical course is 5 to 10 days

›Elevate the affected limb above heart level when resting

›Reduces swelling and speeds healing

›Keep the skin dry and clean

›Gentle washing only

›Moisturize surrounding skin

›Entry portal care

›Apply antifungal cream between toes if tinea pedis present

›Treat for at least 4 weeks

›This prevents recurrence

›Protect wounds and breaks in skin

›Clean dressings

›Avoid trauma to affected area

›Warning signs to return to the emergency department

›Redness spreading beyond the marked border

›Take a photo to compare

›Increasing pain or swelling

›New blisters, dark discoloration, or skin breakdown

›Fever above 38.5 C not improving

›Confusion or feeling much more unwell

›Numbness or loss of sensation over the red area

›No improvement after 48 to 72 hours of antibiotics

›Recurrence prevention

›Treat athlete's foot promptly

12References/r27

Guidelines and key sources

›Society guidelines

›IDSA Clinical Practice Guidelines for Skin and Soft Tissue Infections 2014

›Stevens DL et al. Clin Infect Dis 2014;59(2):e10-52

›Antibiotic duration, coverage recommendations, prophylaxis thresholds

›ACEP Clinical Policy for Skin and Soft Tissue Infections

›Level B recommendation for imaging in suspected necrotizing fasciitis

›Level C recommendation for blood cultures in uncomplicated cases

›Key evidence sources

›Dupuy A et al. Arch Dermatol 1999 — risk factors for erysipelas

›OR 23.8 for skin barrier disruption

›OR 71.2 for lymphedema

›Thomas KS et al. PATCH trial — penicillin prophylaxis for recurrent erysipelas

›NNT 6 for penicillin V 250 mg BID prophylaxis

›69% reduction in recurrence

›Wong CH et al. — LRINEC score development

›Score >= 6 PPV 92% and NPV 96%

›Adjunct tool for necrotizing fasciitis risk stratification

Coding references

›ICD-10 codes

›A46 — Erysipelas

›Primary ICD-10 code

›Applies to classical superficial streptococcal skin infection

›M72.6 — Necrotizing fasciitis

›Use when necrotizing fasciitis confirmed or suspected

›L03 — Cellulitis

›For poorly demarcated deeper skin infections

›B35.3 — Tinea pedis

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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