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Erysipelas

Erysipelas is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Distinct form of cellulitis: notable for acute, well-demarcated, superficial bacterial skin infection with lymphatic involvement almost always caused by Streptococcus pyogenes
  • Usually acute, but a chronic recurrent form can also exist (1)
  • Nonpurulent
  • System(s) affected: skin, exocrine

Epidemiology

  • Predominant age: infants, children, and adults >45 years
  • Greatest in elderly (>75 years)
  • No gender/racial predilection

Incidence
  • Erysipelas occurs in ~1/1,000 persons/year.
  • Incidence on the rise since the 1980s (2)

Prevalence
Unknown

Etiology and Pathophysiology

  • Group A streptococci induce inflammation and activation of the contact system, a proinflammatory pathway with antithrombotic activity, releasing proteinases and proinflammatory cytokines.
  • The generation of antibacterial peptides and the release of bradykinin, a proinflammatory peptide, increase vascular permeability and induce fever and pain.
  • The M proteins from the group A streptococcal cell wall interact with neutrophils, leading to the secretion of heparin-binding protein, an inflammatory mediator that also induces vascular leakage.
  • This cascade of reactions leads to the symptoms seen in erysipelas: fever, pain, erythema, and edema.
  • Group A β-hemolytic streptococci primarily; commonly S. pyogenes, occasionally, other Streptococcus groups C/G
  • Rarely, group B streptococci/Staphylococcus aureus may be involved.

Risk Factors

  • Disruption in the skin barrier (surgical incisions, insect bites, eczematous lesions, local trauma, abrasions, dermatophytic infections, intravenous drug user [IVDU])
  • Chronic diseases (diabetes, malnutrition, nephrotic syndrome, heart failure)
  • Immunocompromised (HIV)/debilitated
  • Fissured skin (especially at the nose and ears)
  • Toe-web intertrigo and lymphedema
  • Leg ulcers/stasis dermatitis
  • Venous/lymphatic insufficiency (saphenectomy, varicose veins of leg, phlebitis, radiotherapy, mastectomy, lymphadenectomy)
  • Alcohol abuse
  • Morbid obesity
  • Recent streptococcal pharyngitis
  • Varicella

General Prevention

  • Good skin hygiene
  • It is recommended that predisposing medical conditions, such as tinea pedis and stasis dermatitis, be appropriately managed first.
  • Men who shave within 5 days of facial erysipelas are more likely to have a recurrence.
  • With recurrences, search for other possible sources of streptococcal infection (e.g., tonsils, sinuses).
  • Compression stockings should be encouraged for patients with lower extremity edema.
  • Consider suppressive prophylactic antibiotic therapy, such as penicillin, in patients with >2 episodes in a 12-month period.

Pediatric Considerations
Group B Streptococcus may be a cause of erysipelas in neonates/infants.

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Citation

Stephens, Mark B., et al., editors. "Erysipelas." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116216/2.1/Erysipelas.
Erysipelas. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116216/2.1/Erysipelas. Accessed June 18, 2019.
Erysipelas. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116216/2.1/Erysipelas
Erysipelas [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 June 18]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116216/2.1/Erysipelas.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Erysipelas ID - 116216 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116216/2.1/Erysipelas PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -