• Distinct form of cellulitis: an acute, well-demarcated, superficial bacterial skin infection (most commonly on face or leg) with lymphatic involvement almost always caused by Streptococcus pyogenes
  • Usually acute, but a chronic recurrent form can also exist
  • Nonpurulent
  • System(s) affected: skin, exocrine


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


  • Erysipelas occurs in ~24/1,000 persons/year (1).
  • Incidence on the rise since the 1980s


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 Streptococcus 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.

There's more to see -- the rest of this topic is available only to subscribers.