Cellulitis

Posted by: admin  :  Category: Dermatology

Cellulitis
Introduction
Background

Cellulitis is an acute infection of skin and soft tissues characterized by localized pain, swelling, tenderness, erythema, and warmth.

The eMedicine Emergency Medicine article Cellulitis and the Medscape CME course Managing the Complicated Skin and Soft Tissue Infection may be of interest.
Pathophysiology

Cellulitis usually follows a break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound. Facial cellulitis of odontogenic origin may also occur. Patients with toe web intertrigo and/or tinea pedis and those with lymphatic obstruction, venous insufficiency, pressure ulcers, and obesity are particularly vulnerable to recurrent episodes of cellulitis.1, 2, 3 Organisms on the skin and its appendages gain entrance to the dermis and multiply to cause cellulitis. The vast majority of cases are caused by Streptococcus pyogenes or Staphylococcus aureus. Occasionally, cellulitis may be caused by the emergence of subjacent osteomyelitis. Cellulitis may rarely result from the metastatic seeding of an organism from a distant focus of infection, especially in immunocompromised individuals. This is particularly common in cellulitis due to Streptococcus pneumoniae and marine vibrios.
Frequency
United States

Because cellulitis is not a reportable disease, the exact prevalence is uncertain; however, it is a relatively common infection. A 2006 study found an incidence rate of 24.6 cases per 1000 person-years.4
International

Cellulitis has been found to account for approximately 3% of emergency medical consultations at one United Kingdom district general hospital.
Mortality/Morbidity

Cellulitis generally is a localized infection. Most patients treated appropriately recover completely. Mortality is rare (5%) but may occur in neglected cases or when cellulitis is due to highly virulent organisms (eg, Pseudomonas aeruginosa). Factors associated with an increased risk of death are the presence of concurrent illness (eg, congestive heart failure, morbid obesity, hypoalbuminemia, renal insufficiency) or complications (eg, shock).5
Race

No racial predilection has been noted.
Sex

No predilection for either sex is usually reported, although a higher incidence among males has been reported in one study.4
Age

No age predilection is usually described; however, recent studies found a higher incidence of cellulitis in general among individuals older than 45 years.2, 4 Moreover, cellulitis at certain anatomic sites may show a predilection for persons in certain age groups.

Facial cellulitis is more common in children younger than 3 years.
Perianal cellulitis is predominantly a disease of children.6

Clinical
History

The incubation period is somewhat organism dependent. Postoperative cellulitis at the surgical site due to group A beta-hemolytic streptococci may develop rather rapidly. On the other hand, cellulitis due to staphylococci usually is delayed in onset.

Patients report local pain and swelling at the site of cellulitis.
The patient may report a history of trauma to the site. Severe bacterial cellulitis may occur as a postsurgical complication, such as following hip replacement7 or liposuction, or secondary to lymphatic occlusion following either radical mastectomy8, 9 or conservative breast surgery10; impaired lymphatic drainage and edema are also considered predisposing factors to leg cellulitis following saphenous vein resection for coronary artery bypass.11 However, cellulitis may follow a trivial injury to the skin (eg, scratch, abrasion, animal bite, intravenous or subcutaneous drug injection, body piercing).12, 13, 14
Fever is common, and chills may be noted, particularly if suppuration has occurred.
Malaise may be present.
Physical

The clinical appearance of cellulitis is shown in Media Files 1-3.

Involved sites are red, hot, swollen, and tender.
Unlike erysipelas, the borders are not elevated or sharply demarcated.
Lymphangitis, regional lymphadenopathy, or both may be present.
Fever is common.
In severe cases, patients may develop hypotension.
Local suppuration may follow if therapy is delayed.
Overlying skin may develop areas of necrosis.
The most commonly involved site is the leg.4, 15
Perianal cellulitis due to group A streptococci is usually observed among children with perianal fissures. It is characterized by perianal erythema and pruritus, painful defecation, and bleeding in the stools.6
Pneumococcal facial cellulitis occurs primarily in young children who are at risk for pneumococcal bacteremia.16, 17 It may manifest as two distinctive clinical syndromes.
Extremity involvement in individuals with diabetes mellitus or substance abuse
Head, neck, and upper torso involvement in individuals with systemic lupus erythematosus, nephrotic syndrome, or hematologic disorders

Causes
In immunocompetent individuals, cellulitis is usually due to S pyogenes and, occasionally, S aureus.5, 18, 19 Isolation of methicillin-resistant S aureus (MRSA) is steadily increasing.20 Bacterial strains may also show multiple resistance to other standard antibiotic treatments, including erythromycin.
Recurrent staphylococcal cellulitis may occur in patients with nasal carriage of staphylococci and those with Job syndrome. S aureus is also the leading cause of soft tissue infections in persons who abuse injection drugs.21
Recurrent cellulitis due to streptococci may be observed in patients with chronic lymphedema (eg, from lymph node dissection, irradiation, Milroy disease, elephantiasis).18, 22 Streptococcal infections are also common in injection drug users.23
Non–group A streptococci (ie, groups B, C, and G) are commonly implicated in cellulitis in patients with lymphatic obstruction or venectomy for coronary artery bypass graft.11, 24
S pneumoniae is an uncommon cause of cellulitis in adults.17, 25, 26 Pneumococcal cellulitis may occur via bacteremia. In a review of pneumococcal skin infection in adults, all such patients had an underlying chronic illness or were immunocompromised by drug or alcohol abuse.27 Pneumococcal facial cellulitis occurs primarily in young children at risk for pneumococcal bacteremia.16, 28
Patients who are immunocompromised with granulocytopenia, such as renal transplant recipients, may develop cellulitis due to infection with other organisms, including gram-negative bacilli (eg, Pseudomonas, Proteus, Serratia, Enterobacter, Citrobacter), anaerobes, other opportunistic pathogens (eg, Helicobacter cinaedi, Fusarium species), mycobacteria, and fungi (eg, Cryptococcus).29, 30, 31, 32, 19, 33, 34, 35 Preseptal cellulitis caused by dermatophytes is rarely observed, mostly in the pediatric age group.36 Persistent cellulitis due to Cryptococcus neoformans infection has also been reported in a patient receiving renal dialysis.37
Escherichia coli may be responsible for cellulitis in patients with nephrotic syndrome.38
Cellulitis from unusual bacterial species, including Enterococcus faecalis, Enterobacteriaceae, and Bacteroides and Clostridium species, may be observed following subcutaneous injections of illegal drugs.39 If Clostridium species or other anaerobes cause the infection, crepitant cellulitis is often observed clinically.
Other uncommon causes of cellulitis include Neisseria meningitidis; Pasteurella multocida, following animal bites; Aeromonas hydrophilia, following contact with fresh water; Streptococcus iniae, a fish pathogen causing infections in aquaculture farms; and Vibrio vulnificus, following contact with seawater. Cellulitis from marine vibrios in hepatopathic patients may also follow ingestion of contaminated raw oysters.40, 41, 42, 43, 44, 45 Haemophilus influenzae has become a rare cause of buccal cellulitis in children after the introduction of the H influenzae type B vaccine.46, 47

19 Responses to “Cellulitis”

  1. David Smith Says:

    My wife has had cellulitis in left lower leg three times in past four years, presently in hospital for another outbreak in same leg. Looks just like the picture you show!

  2. jesus Says:

    cellulitis can mimick deep vein thrombosis?

  3. admin Says:

    Cellulitis may mimic deep venous thrombosis but can often be differentiated by one or more features . Bacterial Skin Infections: Differentiating Cellulitis and Deep Venous Thrombosis). Fever, chills, tachycardia, headache, hypotension, and delirium may precede cutaneous findings by several hours, but many patients do not appear ill. Leukocytosis is common.
    Skin temperature
    Cellulitis : Hot
    Deep Venous Thrombosis :Normal or cool

    Skin color
    Cellulitis :Red
    Deep Venous Thrombosis : Normal or cyanotic

    Skin surface
    Cellulitis :Peau d’orange
    Deep Venous Thrombosis : Smooth

    Lymphangitis and regional lymphadenopathy
    Cellulitis :Frequent
    Deep Venous Thrombosis: Nonexistent

  4. b surya prasad Says:

    sir,
    recently my brother aged about 44 years effected with cellulitis at right leg’s foot. first day it was swelling only. sencond day we contacted corporate hospital and as per advise of doctors immediately admitted in the ahospital. By evening swelling was developed and appeared some bubbles on the foot. The doctor diognised as cellulitis.

    the concern surgeon done first aid on the same day and removed white bubbles and dressing was done. And surgery was carried out within 24 hours and removed all the waste tissues. Now giving anti-boitics. The swelling was come down. Regular dressing is going in the presence of doctor.

    I am grateful if you clarify these points:

    1) It is curable ? If so how many days it will take ?
    2) Is there any food restrictions ?

    Kind regards,

    prasad

  5. marisol Says:

    I have cellulitis and this page give me a lot of information thank you cause doctors never explain to me like you i been having cellulitis every year since 2006

  6. betty Says:

    Now I understand why I ran a fever of 102 two months ago and have had the swelling, redness and hot spot recurring each of the past two months, only now it’s not going away and I have been on antibiotics for 11 days with three more days of antibiotics to go. Having diabetes I will be even more on top of this now. Thank you for a very informative article.

  7. B. Quimby Says:

    I am an instructor at the university of Maryland and would like to use the picture of the leg with cellulitis in a case study that I hope to publish for others to use. Please let me know what I need to do to obtain permission to use the photo. Thanks.
    Boots

  8. admin Says:

    I give you permission

  9. tony Says:

    HAD THIS FOR 10 YEARS NOW. NOT ONCE DID ANY OF MY DOCTORS MENTION THIS IS AN INFECTION….UNTIL A FEW WEEKS AGO WHEN I ENDED UP IN THE HOSPITAL. ONCE ADMITTED I STAYED FOR A WEEK. TREATMENT WAS IV ANTIBIOTICS AND MORPHINE. SEEMS LIKE IT NEVER REALLY GOES AWAY.

  10. Louise Says:

    I have had this more than 25 times over a period of 4 years in both my arms and legs. Like the comment above, I feel as if once one episode is over a new one is starting. I have been prescribed a permanent low dose of antibiotics although this has not helped in the slightest. Painkillers don’t seem to have an effect either, really limiting what I can do.

  11. David Says:

    I have had cellulitis on going for about 10 years. Different locations,(left side of head, right side of head, both sides and face, both legs (once at the same time). The onsets are quick usually 1 to 2 hours and range from mild swelling and colour and raised temperatures of location, to extremes with uncontrolled shaking, muscle weakening to the point of having to crawl. Those cases have been few and far between. Lately I have had frequent episodes (in one now) the seem to happen more frequently in winter when the air is dry. I have permenant discolouration of my left ankle and lower shin. I now keep a filled subscription with me to take as soon as the onset occurs.

  12. Tom K. Says:

    I was admitted to hospital for 6 days due to cellulitis in my right leg back in October (09). I waited 12hrs too long before I realized I needed help. IV antibiotics & painkillers knocked it down but every week upto 6 weeks ago I had pain in the affected ankle along with low-grade fever one to 3 days every week. Today I’m experiencing 99.6 fever with a serious limp and swelling. I too have permanent discoloration on my lower leg where alot of dead skin sloughed off after the initial infection. I am 49yrs old and really don’t want to go through this ordeal again. I am disturbed by these accounts because I don’t want that again.
    I have a picture of it the day I was admitted if the UMD guy would like ( I live 20miles from there).

  13. Vickie Says:

    My husband was just diagnosed with cellulitis a week ago just a few days after a right knee replacement. The infection did not go to the knee. It is mostly in his calf. However he did have redness in the front of his lower leg but not all ove3r. He now has a picc line and is receiving Vancomycin every 12 hours. The first full day after being home from the hospital, he seemed to be doing well. He could move around with a walker or crutches and was in pain but not severe. This morning he is in severe pain when he puts his leg down to try to walk with a walker or crutch. As long as he is not on it he has no severe pain in his calf unless you press an area in his calf. Is this normal? The leg is no longer red, hot or swollen. His leg is a little warm but nothing like it was with the onset of the infection He is currently on Cumadin since he just had surgery. I am worried about clots or is this pain typical with cellulites?

  14. Jack Says:

    I am trying to get over my 17th outbreak since 1992. This is my first outbreak in 4 yrs, and I’ve had it for 3 weeks now. I seem to be getting resistant to the antibiotics. My last episode was 4 yrs ago and took almost 2 months to get rid of. It’s a real problem, since I travel constantly in my job.

  15. Alexis Says:

    My dad was just diagnosed with cellulitis 3 weeks ago. He went to the ER and they kept him there for 1 1/2 days, gave him IV antibiotics and then a week and a half worth of oral antibiotics … but it doesnt seem to be going away. He’s taking his meds like he should be but he doesnt seemed to worried about it. He saw our family doctor today who said to come back in a week, but his leg is swelled up really bad (about the same size as this picture) and it’s practically hard as a rock … what do these symptoms indicate and should he just go back to the ER?? Please help me! My mom and I are really worried about him!!

  16. Vanessa Firsick Says:

    I have cellulitius for fours now. I get at least one a year. I wish it would go away for good. But reading this helped out alilttle bit. If a doctor reads this help me I am going throgh it again rite now.

  17. Deana Says:

    I was diagnosed Apr 16/10 with it in my left hand. Docs have me on IV antibiotics as an out patient. Most of the swelling has gone down but there is still the warmth and an enlarged knuckle. I am 42 and am scared to think this may re-occur.

  18. lora Says:

    Hi. I had this dreadful infection last year but luckily for me it was very quickly diagnosed. My leg is very swollen if I dont wear my support stocking. Im 34 and hate to think i will have to wear this thing for life as my doctor told me that my leg might never be the same again. I spent 2 1/2 wks in hospital and I really hope that it wont come back.

  19. Randi Miller Says:

    I have had cellulitis for 9 consecutive years in either leg from the knee down similiar to the pic. Usually brought on by a cut or scratch. I have learned that getting on antibiotics ASAP after I feel even the slightest discomfort as the infection progresses dramatically reduces the healing time. Compression stockings are a must and keeping the leg elevated several times daily is a huge help. Being overweight does not help my cause either.

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