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:
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 i,nfection 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
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
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.