Cellulitis is a diffuse inflammatory condition of the skin and subcutaneous
tissues. It characteristically presents with localized pain and tenderness,
edema, erythema, and heat. Cellulitis occurs most often in the lower
extremities, but it may also occur in the upper extremities as well as the face
and scalp. It is most often caused by pathogens of the skin such as group A
streptococci (Streptococcus pyogenes) and Staphylococcus aureus;
however, other causative organisms are groups B, C, and G streptococci,
Haemophilus influenzae (periorbital cellulitis in children),
Pseudomonas aeruginosa (cellulitis in immunocompromised hosts), as well
as atypical gram-negative bacteria and cryptococci. S. pyogenes is the
most common cause of erysipelas, a superficial cellulitis seen most often on the
face and scalp; Erysipelothrix rhusiopathiae is the causative organism of
cellulitis among fish and meat handlers; and Mycobacterium marinum causes
cellulitis among patients exposed to water in aquariums and swimming pools.
Erysipelas is a type of superficial cellulitis (most commonly seen in infants,
young children, and elderly), which includes lymphatic involvement and is almost
invariably due to group A streptococci (less commonly, group C or
A history of a preceding injury to the skin such as cuts, insect bites,
trauma, burns, surgical incisions, intravenous catheters, or an underlying
disorder such as stasis dermatitis or psoriasis account often precede the
development of cellulitis. A systemic infection may spread to the skin and
subcutaneous tissue; although rare with cellulitis, an upper respiratory
infection precedes erysipelas in one-third of the patients with this latter
condition. Occasionally, there is no obvious inciting event for either
cellulitis or erysipelas.
- Peripheral vascular disease
- Contaminated wounds
- Systemic infections
- Sinusitis, otitis media, or epiglottitis may precede periorbital
cellulitis, especially in children
- Lymphedema from pelvic surgery, radiation therapy, or lymph node
- Bites of cats and dogs or other animals –
causing infection by Pasturella and a variety of anaerobic
- Venous surgery
|Signs and Symptoms|
- Pain and tenderness
- Erythema, which blanches on palpation
- Indistinct borders
- Crepitus or bullae formation in the soft tissue may be indicative of
- Hypotension or confusion may occur in the case of
- Herpes zoster
- Insect bites
- Contact dermatitis
- Chemical or thermal burns
- Deep vein thrombosis (DVT)
- Giant urticaria
- Lymphatic cutaneous metastases
- Diffuse inflammatory breast carcinoma may mimic erysipelas in that
- Also want to be aware of the possibility of septic or inflammatory
joints, abscess formation, necrotizing fasciitis, and gangrene (see section
A thorough physical examination is performed to determine the portal of entry
of the pathogen. Antimicrobial therapy should not be delayed until laboratory
results are in hand because cellulitis may rapidly progress to a serious
systemic infection. Suspicion of gangrene or abscess warrants surgical consult
Diagnostic tests are used to try to identify the causative organism; however,
the results are often inconsistent and therefore disappointing, isolating the
pathogen in only 10% to 50% of cases. Thus, the diagnosis is usually made
- Gram's stain and culture from an open wound and/or obvious portal of
- Punch biopsy of the lesions
- Fine-needle aspiration of the advancing edge of the cellulitis
- Blood cultures if suspected bacteremia
- WBC count may reveal leukocytosis, common with
- X rays may show air in tissues or periosteal inflammation
- Computed tomography scan, to diagnose orbital cellulitis
- Bone scan if underlying osteomyelitis is suspected
- Doppler studies may be ordered to assess for
- Latex agglutination
- Ankle-brachial indices, pulse volume recordings, and arteriogram if
vascular disease is
Although treatment with antibiotics usually brings rapid relief, patients
should also maintain complete bed rest, immobilization and elevation of the
affected extremity, and cool, wet, sterile, saline dressings for local relief.
Antibiotics are the mainstay of therapy. Analgesics for pain may also be
- For streptococcal origin: aqueous penicillin G (600,000 units)
injection followed by intramuscular procaine penicillin (600,000 units every 8
to 12 hours). Alternatives may be needed for penicillin-resistant strains of
- For staphylococcal origin: dicloxacillin, 0.25 to 0.5 g orally every
- For penicillin-allergic adults: erythromycin, 0.5 g orally every six
Cellulitis in high-risk patients and/or if systemic infection or
complications present or suspected, hospital observation
- For staphylococcal or streptococcal origin: nafcillin, 1.0 to 2.0 g
intravenously every four hours or cefazolin 1.0 g IV q 8 hours
- For penicillin-allergic adults: vancomycin, 1.0 to 1.5 g/day
intravenously (facial erysipelas); erythromycin or azithromycin for
- For gram-negative bacilli: an aminoglycoside such as gentamicin
- For diabetic patients: parenteral cefazolin or cefoxitin plus
gentamicin, or clindamycin and
If antibiotics fail to produce a prompt clinical response, surgery may be
necessary to drain any underlying abscess.
|Complementary and Alternative
Cellulitis can progress rapidly and, as stated earlier, antibiotic therapy is
recommended to prevent systemic bacteremia. Most CAM therapies have not yet been
scientifically evaluated for use in cellulitis.
According to the results of one case study, though, magnet therapy may help
heal chronic wounds. The patient was a woman with a history of cellulitis
originating at the site of an abdominal scar. Conventional treatments such as
antibiotic therapies, antifungal medications, and wet-to-dry dressings were used
over the course of a year but failed to heal this persistent wound. There were
no obvious medical complications retarding wound healing. A permanent magnet,
650 gauss in strength, was placed on top of a gauze dressing and secured with
tape. No other changes were made in a dressing protocol of antibiotic ointment
covered with gauze and changed twice daily. The magnet was worn at all times
except when the dressing was being changed. On her first return visit 11 days
after the application of the magnet, the wound was considerably smaller in size.
The following week, there was no change in size but the reddened scar tissue was
lighter in color and smoother in texture. By the last visit, 4 weeks after
beginning magnet therapy, the wound had completely healed (Szor and Topp 1998).
There are many theories about how magnet therapy works to reduce pain and
inflammation; however, none are definitive. Theories include: increased
circulation to the affected area, with removal of metabolic waste products and
delivery of nutrients; pain relief due to neural stimulation; changes in
cellular conductivity caused by realignment of molecules in cell membranes;
influence on the pineal gland, resulting in altered production of melatonin,
serotonin, and various enzymes; and decreased levels of cholinesterase, or
inhibition of its accumulation, thereby altering metabolism of neurotransmitters
at the synapse (Szor and Topp 1998). It will be interesting to see if future
research replicates these results.
Specific nutrients have not been studied in relationship to cellulitis.
However, vitamins known to be supportive of the immune system include vitamin C,
zinc, and vitamins A and E. The latter two are also thought to have specific
benefit for the skin (Keller and Fenske 1998). In addition, flavonoids appear to
be useful in reducing swelling for lymphedema and may also be helpful in
treating swelling associated with cellulitis (Mortimer 1997). There is, however,
no known scientific literature confirming the effectiveness of this latter
application. Bromelain may also be used clinically to reduce inflammation and
edema (250 to 500 mg tid); it works well in combination with quercetin, a
flavonoid. Please see corresponding monographs on each of these topics for
Although there are no studies validating their use for cellulitis
specifically, herbs that provide immune support may be beneficial. Echinacea
(Echinacea spp.) is widely used in clinical practice for immunomodulation
in the case of an infection; yarrow (Achillea millefolium) is used for
similar purposes. Comfrey root (Symphytum officinale) is an
anti-inflammatory from which a paste can be made and applied topically bid to
speed healing and minimize superinfection (Blumenthal et al. 2000). Goldenseal
root (Hydrastis canadensis) and slippery elm (Ulmus fulva)
may be added to a topical comfrey paste for enhanced therapeutic
Homeopathic treatment can address both constitutional and acute
aspects of disease in general. In homeopathic terminology, the constitutional
state reflects a pattern of underlying vulnerability or weakness that is unique
to the individual and persists throughout that person's life. Symptoms tend to
alternate over time, and treatment consists of selecting the appropriate remedy
specific for the patient's constitutional type. By contrast, in acute
conditions, such as cellulitis, a remedy may be administered without reference
to any particular constitutional state (Ullman 1995).
Morrison describes several homeopathic remedies for use in erysipelas:
Apis, Borax, Cantharis, Crotalus horridus,
Graphites, Lachesis, Mercurius, Rhus toxicodendron,
and Sulphur (Morrison 1993). French and Belgian homeopaths have been
treating cellulitis clinically with homeopathic remedies since the 1960s. It is
best to consult a licensed, certified homeopath to treat an individual most
Acupuncture and other traditional Chinese medicine practices may be helpful
in addressing the underlying etiology and enhancing immune function; however,
this application in the treatment of cellulitis has not been investigated.
Massage is contraindicated in cases of active infection. However, when used
to promote lymphatic drainage, as in the case of stasis or lymphedema, massage
together with compression and exercise may be a useful prophylactic treatment in
the case of recurrent cellulitis secondary to these etiologies (Mortimer
Cellulitis should be treated as a dermatologic emergency, and all patients
should be carefully followed. Otherwise, serious complications such as gangrene
Secondary bacterial infections are not uncommon. All patients must be
monitored to be sure that the cellulitis resolves satisfactorily.
Immunocompromised patients will need more aggressive
Complications of cellulitis are uncommon but are most often seen in very
young children, the elderly, or in immunocompromised patients.
- Metastatic abscess
- Thrombophlebitis (predominantly in lower extremities of the
Although antibiotic therapy most often cures the cellulitis, death from
complications may occur. A thorough history is important as some patients tend
to develop recurrent cellulitis, often in the same area, leading to permanent
changes. Long-term neglect and poor skin hygiene may result in a rare condition,
elephantiasis nostras, which is characterized by thickened skin and verrucous
lesions resembling crowded wart-like growths.
Patients on a maternity ward who develop cellulitis should be temporarily
isolated as a precaution.
Blumenthal M, Busse WR, Goldberg A, et al., eds. The Complete German
Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston,
Mass: Integrative Medicine Communications; 1998:116, 121-123, 233-234.
Conn RB, et al. Current Diagnosis. Philadelphia, Pa: W.B. Saunders;
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:829.
Keller KL, Fenske NA. Uses of vitamins A, C and E and related compounds in
dermatology: a review. J Am Acad Dermatol. 1998;39(4 Pt1):611-625.
Mandell GL, et al. Principles and Practice of Infectious Diseases. 4th
ed. New York, NY: Churchill Livingstone; 1995:913-919.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:27-29, 68, 97, 144, 171,
215-219, 246, 324, 327, 368-374.
Mortimer PS. Therapy approaches for lymphedema. Angiology. 1997;
Moschella SL, Hurley HJ. Dermatology. 3rd ed. Philadelphia, Pa: W.B.
Saunders; 1992:183, 223, 728-732.
Rosen P, et al. Emergency Medicine: Concepts and Clinical Practice.
Vol. III. St. Louis, Mo; Mosby; 1998:2669-2672, 2862.
Sauer GC. Manual of Skin Diseases. 6th ed. Philadelphia, Pa:
Schwartz SI, et al. Principles of Surgery. 7th ed. New York, NY:
Szor JK, Topp R. Use of magnet therapy to heal an abdominal wound: a case
study. Ostomy Wound Manage. 1998;44(5):24-29.
Ullman D. The Consumer's Guide to Homeopathy. New York, NY:
Copyright © 2007 Drugs Area
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information relating to general principles
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