Cellulitis

Last updated
Cellulitis
Cellulitis3.jpg
Skin cellulitis
Specialty Infectious disease, dermatology
Symptoms Red, hot, painful area of skin, fever [1] [2]
Duration7–10 days [2]
Causes Bacteria [1]
Risk factors Break in the skin, obesity, leg swelling, old age [1]
Diagnostic method Based on symptoms [1] [3]
Differential diagnosis Deep vein thrombosis, stasis dermatitis, erysipelas, Lyme disease, necrotizing fasciitis [1] [4] [5]
TreatmentElevation of the affected area [4]
Medication Antibiotics such as cephalexin [1] [6]
Frequency21.2 million (2015) [7]
Deaths16,900 (2015) [8]

Cellulitis is usually [9] a bacterial infection involving the inner layers of the skin. [1] It specifically affects the dermis and subcutaneous fat. [1] Signs and symptoms include an area of redness which increases in size over a few days. [1] The borders of the area of redness are generally not sharp and the skin may be swollen. [1] While the redness often turns white when pressure is applied, this is not always the case. [1] The area of infection is usually painful. [1] Lymphatic vessels may occasionally be involved, [1] [4] and the person may have a fever and feel tired. [2]

Contents

The legs and face are the most common sites involved, although cellulitis can occur on any part of the body. [1] The leg is typically affected following a break in the skin. [1] Other risk factors include obesity, leg swelling, and old age. [1] For facial infections, a break in the skin beforehand is not usually the case. [1] The bacteria most commonly involved are streptococci and Staphylococcus aureus . [1] In contrast to cellulitis, erysipelas is a bacterial infection involving the more superficial layers of the skin, present with an area of redness with well-defined edges, and more often is associated with a fever. [1] The diagnosis is usually based on the presenting signs and symptoms, while a cell culture is rarely possible. [1] [3] Before making a diagnosis, more serious infections such as an underlying bone infection or necrotizing fasciitis should be ruled out. [4]

Treatment is typically with antibiotics taken by mouth, such as cephalexin, amoxicillin or cloxacillin. [1] [6] Those who are allergic to penicillin may be prescribed erythromycin or clindamycin instead. [6] When methicillin-resistant S. aureus (MRSA) is a concern, doxycycline or trimethoprim/sulfamethoxazole may, in addition, be recommended. [1] There is concern related to the presence of pus or previous MRSA infections. [1] [2] Elevating the infected area may be useful, as may pain killers. [4] [6]

Potential complications include abscess formation. [1] Around 95% of people are better after 7 to 10 days of treatment. [2] Those with diabetes, however, often have worse outcomes. [10] Cellulitis occurred in about 21.2 million people in 2015. [7] In the United States about 2 of every 1,000 people per year have a case affecting the lower leg. [1] Cellulitis in 2015 resulted in about 16,900 deaths worldwide. [8] In the United Kingdom, cellulitis was the reason for 1.6% of admissions to a hospital. [6]

Signs and symptoms

The typical signs and symptoms of cellulitis are an area that is red, hot, and painful. The photos shown here are of mild to moderate cases and are not representative of the earlier stages of the condition.[ citation needed ]

Complications

Potential complications may include abscess formation, fasciitis, and sepsis. [1] [11]

Causes

Cellulitis is usually, but not always, [9] caused by bacteria that enter and infect the tissue through breaks in the skin. Group A Streptococcus and Staphylococcus are the most common causes of the infection and may be found on the skin as normal biota in healthy individuals. [12]

About 80% of cases of Ludwig's angina, or cellulitis of the submandibular space, are caused by dental infections. Mixed infections, due to both aerobes and anaerobes, are commonly associated with this type of cellulitis. Typically, this includes alpha-hemolytic streptococci, staphylococci, and bacteroides' groups. [13]

Predisposing conditions for cellulitis include an insect or spider bite, blistering, an animal bite, tattoos, pruritic (itchy) skin rash, recent surgery, athlete's foot, dry skin, eczema, injecting drugs (especially subcutaneous or intramuscular injection or where an attempted intravenous injection "misses" or blows the vein), pregnancy, diabetes, and obesity, which can affect circulation, as well as burns and boils, although debate exists as to whether minor foot lesions contribute. Occurrences of cellulitis may also be associated with the rare condition hidradenitis suppurativa or dissecting cellulitis. [14]

The appearance of the skin assists a doctor in determining a diagnosis. A doctor may also suggest blood tests, a wound culture, or other tests to help rule out a blood clot deep in the veins of the legs. Cellulitis in the lower leg is characterized by signs and symptoms similar to those of a deep vein thrombosis, such as warmth, pain, and swelling (inflammation).

Reddened skin or rash may signal a deeper, more serious infection of the inner layers of skin. Once below the skin, the bacteria can spread rapidly, entering the lymph nodes and the bloodstream and spreading throughout the body. This can result in influenza-like symptoms with a high temperature and sweating or feeling very cold with shaking, as the affected person cannot get warm. [14]

In rare cases, the infection can spread to the deep layer of tissue called the fascial lining. Necrotizing fasciitis, also called by the media "flesh-eating bacteria", is an example of a deep-layer infection. It is a medical emergency. [15]

Risk factors

The elderly and those with a weakened immune system are especially vulnerable to contracting cellulitis. [ citation needed ] Diabetics are more susceptible to cellulitis than the general population because of impairment of the immune system; they are especially prone to cellulitis in the feet, because the disease causes impairment of blood circulation in the legs, leading to diabetic foot or foot ulcers. Poor control of blood glucose levels allows bacteria to grow more rapidly in the affected tissue and facilitates rapid progression if the infection enters the bloodstream. Neural degeneration in diabetes means these ulcers may not be painful, thus often become infected. Those who have had poliomyelitis are also prone because of circulatory problems, especially in the legs.[ citation needed ]

Immunosuppressive drugs, and other illnesses or infections that weaken the immune system, are also factors that make infection more likely. Chickenpox and shingles often result in blisters that break open, providing a gap in the skin through which bacteria can enter. Lymphedema, which causes swelling on the arms and/or legs, can also put an individual at risk.[ citation needed ] Diseases that affect blood circulation in the legs and feet, such as chronic venous insufficiency and varicose veins, are also risk factors for cellulitis.[ citation needed ]

Cellulitis is also common among dense populations sharing hygiene facilities and common living quarters, such as military installations, college dormitories, nursing homes, oil platforms, and homeless shelters.[ citation needed ]

Diagnosis

Cellulitis is most often a clinical diagnosis, readily identified in many people by history and physical examination alone, with rapidly spreading areas of cutaneous swelling, redness, and heat, occasionally associated with inflammation of regional lymph nodes. While classically distinguished as a separate entity from erysipelas by spreading more deeply to involve the subcutaneous tissues, many clinicians may classify erysipelas as cellulitis. Both are often treated similarly, but cellulitis associated with furuncles, carbuncles, or abscesses is usually caused by S. aureus , which may affect treatment decisions, especially antibiotic selection. [16] Skin aspiration of nonpurulent cellulitis, usually caused by streptococcal organisms, is rarely helpful for diagnosis, and blood cultures are positive in fewer than 5% of all cases. [16]

It is important to evaluate for co-existent abscess, as this finding usually requires surgical drainage as opposed to antibiotic therapy alone. Physicians' clinical assessment for abscess may be limited, especially in cases with extensive overlying induration, but use of bedside ultrasonography performed by an experienced practitioner readily discriminates between abscess and cellulitis and may change management in up to 56% of cases. [17] Use of ultrasound for abscess identification may also be indicated in cases of antibiotic failure. Cellulitis has a characteristic "cobblestoned" appearance indicative of subcutaneous edema without a defined hypoechoic, heterogeneous fluid collection that would indicate abscess. [18]

Differential diagnosis

Other conditions that may mimic cellulitis include deep vein thrombosis, which can be diagnosed with a compression leg ultrasound, and stasis dermatitis, which is inflammation of the skin from poor blood flow. Signs of a more severe infection such as necrotizing fasciitis or gas gangrene that would require prompt surgical intervention include purple bullae, skin sloughing, subcutaneous edema, and systemic toxicity. [16] Misdiagnosis can occur in up to 30% of people with suspected lower-extremity cellulitis, leading to 50,000 to 130,000 unnecessary hospitalizations and $195 to $515 million in avoidable healthcare spending annually in the United States. [19] Evaluation by dermatologists for cases of suspected cellulitis has been shown to reduce misdiagnosis rates and improve patient outcomes. [20] [21]

Associated musculoskeletal findings are sometimes reported. When it occurs with acne conglobata, hidradenitis suppurativa, and pilonidal cysts, the syndrome is referred to as the follicular occlusion triad or tetrad. [22]

Lyme disease can be misdiagnosed as cellulitis. The characteristic bullseye rash does not always appear in Lyme disease (the rash may not have a central or ring-like clearing, or not appear at all). [23] Factors supportive of Lyme include recent outdoor activities where Lyme is common and rash at an unusual site for cellulitis, such as armpit, groin, or behind the knee. [24] [23] Lyme can also result in long-term neurologic complications. [25] The standard treatment for cellulitis, cephalexin, is not useful in Lyme disease. [5] When it is unclear which one is present, the IDSA recommends treatment with cefuroxime axetil or amoxicillin/clavulanic acid, as these are effective against both infections. [5]

Prevention

In those who have previously had cellulitis, the use of antibiotics may help prevent future episodes. [26] This is recommended by CREST for those who have had more than two episodes. [6] A 2017 meta-analysis found a benefit of preventative antibiotics for recurrent cellulitis in the lower limbs, but the preventative effects appear to diminish after stopping antibiotic therapy. [27]

Treatment

Antibiotics are usually prescribed, with the agent selected based on suspected organism and presence or absence of purulence, [16] although the best treatment choice is unclear. [28] If an abscess is also present, surgical drainage is usually indicated, with antibiotics often prescribed for co-existent cellulitis, especially if extensive. [17] Pain relief is also often prescribed, but excessive pain should always be investigated, as it is a symptom of necrotizing fasciitis. Elevation of the affected area is often recommended. [29]

Steroids may speed recovery in those on antibiotics. [1]

Antibiotics

Antibiotics choices depend on regional availability, but a penicillinase-resistant semisynthetic penicillin or a first-generation cephalosporin is currently recommended for cellulitis without abscess. [16] A course of antibiotics is not effective in between 6 and 37% of cases. [30]

Epidemiology

Cellulitis in 2015 resulted in about 16,900 deaths worldwide, up from 12,600 in 2005. [8]

Cellulitis is a common global health burden, with more than 650,000 admissions per year in the United States alone. In the United States, an estimated 14.5 million cases annually of cellulitis account for $3.7 billion in ambulatory care costs alone. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown. In the 15% of cellulitis cases in which organisms are identified, most are due to β-hemolytic Streptococcus and Staphylococcus aureus. [31]

Other animals

Horses may acquire cellulitis, usually secondarily to a wound (which can be extremely small and superficial) or to a deep-tissue infection, such as an abscess or infected bone, tendon sheath or joint. [32] [33] Cellulitis from a superficial wound usually creates less lameness (grade 1–2 of 5) than that caused by septic arthritis (grade 4–5). The horse exhibits inflammatory edema, which is hot, painful swelling. This swelling differs from stocking up in that the horse does not display symmetrical swelling in two or four legs, but in only one leg. This swelling begins near the source of infection, but eventually continues down the leg. In some cases, the swelling also travels distally. Treatment includes cleaning the wound and caring for it properly, the administration of NSAIDs, such as phenylbutazone, cold hosing, applying a sweat wrap or a poultice, and mild exercise.[ citation needed ]

See also

Related Research Articles

<span class="mw-page-title-main">Abscess</span> Localized collection of pus that has built up within the tissue of the body

An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends beyond the swelling. Carbuncles and boils are types of abscess that often involve hair follicles, with carbuncles being larger. A cyst is related to an abscess, but it contains a material other than pus, and a cyst has a clearly defined wall.

<span class="mw-page-title-main">Erysipelas</span> Human disease from a bacterial infection of the skin

Erysipelas is a relatively common bacterial infection of the superficial layer of the skin, extending to the superficial lymphatic vessels within the skin, characterized by a raised, well-defined, tender, bright red rash, typically on the face or legs, but which can occur anywhere on the skin. It is a form of cellulitis and is potentially serious.

<span class="mw-page-title-main">Group A streptococcal infection</span> Medical condition

Group A streptococcal infections are a number of infections with Streptococcus pyogenes, a group A streptococcus (GAS). S. pyogenes is a species of beta-hemolytic Gram-positive bacteria that is responsible for a wide range of infections that are mostly common and fairly mild. If the bacteria enter the bloodstream an infection can become severe and life-threatening, and is called an invasive GAS (iGAS).

<span class="mw-page-title-main">Gangrene</span> Type of tissue death by infection or lack of blood supply

Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the gangrene is caused by an infectious agent, it may present with a fever or sepsis.

<span class="mw-page-title-main">Necrotizing fasciitis</span> Infection that results in the death of the bodys soft tissue

Necrotizing fasciitis (NF), also known as flesh-eating disease, is a bacterial infection that results in the death of parts of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms usually include red or purple skin in the affected area, severe pain, fever, and vomiting. The most commonly affected areas are the limbs and perineum.

<span class="mw-page-title-main">Septic arthritis</span> Medical condition

Acute septic arthritis, infectious arthritis, suppurative arthritis, pyogenic arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, heat and pain in a single joint associated with a decreased ability to move the joint. Onset is usually rapid. Other symptoms may include fever, weakness and headache. Occasionally, more than one joint may be involved, especially in neonates, younger children and immunocompromised individuals. In neonates, infants during the first year of life, and toddlers, the signs and symptoms of septic arthritis can be deceptive and mimic other infectious and non-infectious disorders.

<span class="mw-page-title-main">Boil</span> Medical condition (infection)

A boil, also called a furuncle, is a deep folliculitis, which is an infection of the hair follicle. It is most commonly caused by infection by the bacterium Staphylococcus aureus, resulting in a painful swollen area on the skin caused by an accumulation of pus and dead tissue. Boils are therefore basically pus-filled nodules. Individual boils clustered together are called carbuncles. Most human infections are caused by coagulase-positive S. aureus strains, notable for the bacteria's ability to produce coagulase, an enzyme that can clot blood. Almost any organ system can be infected by S. aureus.

Nocardiosis is an infectious disease affecting either the lungs or the whole body. It is due to infection by a bacterium of the genus Nocardia, most commonly Nocardia asteroides or Nocardia brasiliensis.

<span class="mw-page-title-main">Peritonsillar abscess</span> Pus behind the tonsil due to an infection

Peritonsillar abscess (PTA), also known as quinsy, is an accumulation of pus due to an infection behind the tonsil. Symptoms include fever, throat pain, trouble opening the mouth, and a change to the voice. Pain is usually worse on one side. Complications may include blockage of the airway or aspiration pneumonitis.

<span class="mw-page-title-main">Epiglottitis</span> Inflammation of the epiglottis

Epiglottitis is the inflammation of the epiglottis—the flap at the base of the tongue that prevents food entering the trachea (windpipe). Symptoms are usually rapid in onset and include trouble swallowing which can result in drooling, changes to the voice, fever, and an increased breathing rate. As the epiglottis is in the upper airway, swelling can interfere with breathing. People may lean forward in an effort to open the airway. As the condition worsens, stridor and bluish skin may occur.

<span class="mw-page-title-main">Paronychia</span> Medical condition

Paronychia is an inflammation of the skin around the nail, which can occur suddenly, when it is usually due to the bacterium Staphylococcus aureus, or gradually when it is commonly caused by the fungus Candida albicans. The term is from Greek: παρωνυχία from para 'around', onyx 'nail', and the abstract noun suffix -ia.

A skin infection is an infection of the skin in humans and other animals, that can also affect the associated soft tissues such as loose connective tissue and mucous membranes. They comprise a category of infections termed skin and skin structure infections (SSSIs), or skin and soft tissue infections (SSTIs), and acute bacterial SSSIs (ABSSSIs). They are distinguished from dermatitis, although skin infections can result in skin inflammation.

<span class="mw-page-title-main">Orbital cellulitis</span> Inflammation of eye tissues

Orbital cellulitis is inflammation of eye tissues behind the orbital septum. It is most commonly caused by an acute spread of infection into the eye socket from either the adjacent sinuses or through the blood. It may also occur after trauma. When it affects the rear of the eye, it is known as retro-orbital cellulitis.

<span class="mw-page-title-main">Dental abscess</span> Medical condition

A dental abscess is a localized collection of pus associated with a tooth. The most common type of dental abscess is a periapical abscess, and the second most common is a periodontal abscess. In a periapical abscess, usually the origin is a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth. This can be caused by tooth decay, broken teeth or extensive periodontal disease. A failed root canal treatment may also create a similar abscess.

<span class="mw-page-title-main">Pathogenic bacteria</span> Disease-causing bacteria

Pathogenic bacteria are bacteria that can cause disease. This article focuses on the bacteria that are pathogenic to humans. Most species of bacteria are harmless and are often beneficial but others can cause infectious diseases. The number of these pathogenic species in humans is estimated to be fewer than a hundred. By contrast, several thousand species are part of the gut flora present in the digestive tract.

Mouth infections, also known as oral infections, are a group of infections that occur around the oral cavity. They include dental infection, dental abscess, and Ludwig's angina. Mouth infections typically originate from dental caries at the root of molars and premolars that spread to adjacent structures. In otherwise healthy patients, removing the offending tooth to allow drainage will usually resolve the infection. In cases that spread to adjacent structures or in immunocompromised patients, surgical drainage and systemic antibiotics may be required in addition to tooth extraction. Since bacteria that normally reside in the oral cavity cause mouth infections, proper dental hygiene can prevent most cases of infection. As such, mouth infections are more common in populations with poor access to dental care or populations with health-related behaviors that damage one's teeth and oral mucosa. This is a common problem, representing nearly 36% of all encounters within the emergency department related to dental conditions.

Skin and skin structure infections (SSSIs), also referred to as skin and soft tissue infections (SSTIs), or acute bacterial skin and skin structure infections (ABSSSIs), are infections of skin and associated soft tissues. Historically, the pathogen involved has most frequently been a bacterial species—always, since redescription of SSSIs as ABSSSIs—and as such, these infections require treatment by antibiotics.

Perianal cellulitis, also known as perianitis or perianal streptococcal dermatitis, is a bacterial infection affecting the lower layers of the skin (cellulitis) around the anus. It presents as bright redness in the skin and can be accompanied by pain, difficulty defecating, itching, and bleeding. This disease is considered a complicated skin and soft tissue infection (cSSTI) because of the involvement of the deeper soft tissues.

Stasis papillomatosis is a disease characterized by chronic congestion of the extremities, with blood circulation interrupted in a specific area of the body. A consequence of this congestion and inflammation is long-term lymphatic obstruction. It is also typically characterized by the appearance of numerous papules. Injuries can range from small to large plates composed of brown or pink, smooth or hyperkeratotic papules. The most typical areas where injuries occur are the back of the feet, the toes, the legs, and the area around a venous ulcer formed in the extremities, although the latter is the rarest of all. These injuries include pachydermia, lymphedema, lymphomastic verrucosis and elephantosis verrucosa. The disease can be either localized or generalized; the localized form makes up 78% of cases. Treatment includes surgical and pharmaceutical intervention; indications for partial removal include advanced fibrotic lymphedema and elephantiasis. Despite the existence of these treatments, chronic venous edema, which is a derivation of stasis papillomatosis, is only partially reversible. The skin is also affected and its partial removal may mean that the skin and the subcutaneous tissue are excised. A side effect of the procedure is the destruction of existing cutaneous lymphatic vessels. It also risks papillomatosis, skin necrosis and edema exacerbation.

<span class="mw-page-title-main">Diabetic foot infection</span> Medical condition

Diabetic foot infection is any infection of the foot in a diabetic person. The most frequent cause of hospitalization for diabetic patients is due to foot infections. Symptoms may include pus from a wound, redness, swelling, pain, warmth, tachycardia, or tachypnea. Complications can include infection of the bone, tissue death, amputation, or sepsis. They are common and occur equally frequently in males and females. Older people are more commonly affected.

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  32. ↑ Adam EN, Southwood LL (August 2006). "Surgical and traumatic wound infections, cellulitis, and myositis in horses". Veterinary Clinics of North America: Equine Practice. 22 (2): 335–61, viii. doi:10.1016/j.cveq.2006.04.003. PMID   16882479.
  33. ↑ Fjordbakk CT, Arroyo LG, Hewson J (February 2008). "Retrospective study of the clinical features of limb cellulitis in 63 horses". Veterinary Record. 162 (8): 233–36. doi:10.1136/vr.162.8.233. PMID   18296664. S2CID   18579931.

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