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Wingfield E. Rehmus

, MD, MPH, University of British Columbia

Last full review/revision Feb 2021| Content last modified Feb 2021

Erysipelas is a type of superficial cellulitis with dermal lymphatic involvement. Diagnosis is clinical. Treatment is with oral or IV antibiotics.

(See also Overview of Bacterial Skin Infections.)

Erysipelas should not be confused with erysipeloid, a skin infection caused by Erysipelothrix.

Erysipelas is characterized clinically by shiny, raised, indurated, and tender plaques with distinct margins. High fever, chills, and malaise frequently accompany erysipelas. There is also a bullous form of erysipelas.

Manifestations of Erysipelas

Erysipelas is most often caused by group A (or rarely group C or G) beta-hemolytic streptococci and occurs most frequently on the legs and face. However, other causes have been reported, including Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]), Klebsiella pneumoniae, Haemophilus influenzae, Escherichia coli, Staphylococcus warneri, Streptococcus pneumoniae, Streptococcus pyogenes, and Moraxella species.

Erysipelas may be recurrent and may result in chronic lymphedema. Complications of erysipelas commonly include thrombophlebitis, abscesses, and gangrene.

Diagnosis of Erysipelas

  • Clinical evaluation
  • Blood culture

Diagnosis of erysipelas is by characteristic appearance; blood culture is done in toxic-appearing patients.

Erysipelas of the face must be differentiated from herpes zoster, angioedema, and contact dermatitis. Diffuse inflammatory breast cancer may also be mistaken for erysipelas.

Treatment of Erysipelas

  • Oral or IV antibiotics

Antibiotics of choice for erysipelas include the following (1):

  • Routine, first-line oral therapy: Penicillin V 500 mg 4 times a day for ≥ 2 weeks
  • Alternative oral therapy (eg, for penicillin-allergic patients): Erythromycin 500 mg 4 times a day for 10 days (however, macrolide resistance in streptococci is growing)
  • First-line parenteral therapy (for severe cases): Penicillin G 1.2 million units IV every 6 hours, followed after 36 to 48 hours by oral therapy with penicillin V 500 mg 4 times a day
  • Alternative parenteral therapy (eg, for penicillin-allergic patients): Ceftriaxone 1 g IV every 24 hours or cefazolin 1 to 2 g IV every 8 hours, followed after 36 to 48 hours by oral therapy with erythromycin 500 mg 4 times a day for 5 to 10 days
  • Infections with methicillin-sensitive S. aureus: Dicloxacillin 500 mg orally 4 times a day for 10 days

Duration of treatment is based mainly on clinical response rather than a fixed interval.

In Europe, pristinamycin and roxithromycin have been shown to be good choices for erysipelas.

MRSA is not common in patients with erysipelas, and adding antibiotics to cover MRSA generally adds limited additional benefit. However, if MRSA is identified through culture or if MRSA is strongly suspected, an appropriate antibiotic such as clindamycin, trimethoprim/sulfamethoxazole, linezolid, doxycycline, or vancomycin can be added.

Bed rest and leg elevation are helpful for leg erysipelas. Cold packs and analgesics may relieve local discomfort. Fungal foot infections may be an entry site for infection and may require antifungal treatment to prevent recurrence. Compression therapy (using, for example, Unna paste boots and compression socks) may also be of benefit for lower-extremity erysipelas.

Treatment reference

  • 1. Brindle R, Williams OM, Barton E, Featherstone P: Assessment of antibiotic treatment of cellulitis and erysipelas: A systematic review and meta-analysis. JAMA Dermatol 155(9):1033–1040, 2019. doi: 10.1001/jamadermatol.2019.0884

Key Points

  • Consider erysipelas with shiny, raised, indurated, and tender plaques that have distinct margins, particularly if there are systemic signs (eg, fever, chills, malaise).
  • Treat erysipelas with oral penicillin or, in penicillin-allergic patients, erythromycin; in severe cases, use parenteral penicillin or, in penicillin-allergic patients, ceftriaxone or cefazolin.
  • Treat methicillin-sensitive S. aureus infections with dicloxacillin, but treat suspected MRSA with oral clindamycin or trimethoprim/sulfamethoxazole or parenteral vancomycin or linezolid.

Drugs Mentioned In This Article

Drug Name Select Trade
Dicloxacillin No US brand name
Ceftriaxone ROCEPHIN
clindamycin CLEOCIN
vancomycin VANCOCIN
cefazolin ANCEF, KEFZOL
linezolid ZYVOX

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