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- 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)
- System(s) affected: skin, exocrine
- Predominant age: infants, children, and adults >45 years
- Greatest in elderly (>75 years)
- No gender/racial predilection
- Erysipelas occurs in ~1/1,000 persons/year.
- Incidence on the rise since the 1980s (2)
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.
- 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
- 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.
Group B Streptococcus may be a cause of erysipelas in neonates/infants.