Erysipelas A46

Author: Prof. Dr. med. Peter Altmeyer

Co-Autors: Jeton Luzha, Hadrian Tran

Our authors

Last updated on: 29.10.2020

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Synonym(s)

Cellulite; erysipelas; Erysipelas; Erysipelas gangrenous; Erysipelas phlegmonous; Facial Rose; Mucosal erysipelas; Rose; Rotlauf; Streptodermia cutanea lymphatica

Definition
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Acute, non-purulent, febrile, often accompanied by chills, usually asymptomatic, local bacterial infection of the skin, which spreads rapidly lymphogenic and interstitially, with jagged, painful redness and swelling of the skin, and also painful lymphangitis and adenitis.

Pathogen
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β-haemolytic group A streptococci, also representatives of groups B,C and G.

Recent studies indicate that in bullous erysipelas as well as in necrotizing forms, staphylococci (Staphylooccus aureus), very rarely also pneumococci (especially in immunocompromised persons) can play a pathogenetic role (see also MRSA).

Also Gram-negative pathogens (e.g. E. coli, Pseudomonas aeruginosa) can have a pathogenetic significance in rare cases, especially in immunocompromised patients.

Occurrence/Epidemiology
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Incidence: 100 per 100,000 persons/year

Etiopathogenesis
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Penetration of streptococci through the skin into the cutaneous lymphatic system (often after tinea pedum or minor mechanical trauma ["erysipelas"]). Persistent lymphedema is a pathogen for infection (e.g. edema after long saphenectomy in bypass surgery).

Manifestation
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Preferably adults between the ages of 20 and 70 . Lj. In larger studies the average age is about 50 years. Children and adolescents are less frequently affected.

Localization
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The possible entry ports determine the predilection sites, besides the face the lower legs, with a certain distance between erysipelas and the entry port.

  • Extremities:
    • Lower legs (about 70% of cases)
    • Forearms (about 12% of cases)
  • Face (about 13% of cases): mainly cheek area, often bilateral, symmetrical (DD: dermatomyositis; systemic lupus erythematosus).
  • Remark: the nasopharynx of the affected persons is an important source of germs (germ carriers of Str. pyogenes in 20-30% of young adults - Nayak N et al. 2016)
  • trunk (about 3% of cases).

Laboratory
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Leukocytosis with neutrophilia, BSG and CRP elevation. ASL and anti-streptodornase B(ABD) titers elevated.

Histology
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Variable picture depending on the acuteity of the infection. Initial perivascular infiltrate from lymphocytes, neutrophils and isolated eosinophils. Prominent edema of the upper dermis with dilated lymphatic vessels and bulging erythrocyte-filled blood vessels. Increasingly the infiltrate is dominated by a neutrophil component. Occasionally erythrocyte extravasations are observed in uncomplicated infections. The hemorrhagic component may dominate in hemorrhagic erysipelas. Pathogen detection is not successful!

Diagnosis
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Clinical picture with the typical triad (E = erythema; F = fever; L = lymphadenitis)

Differential diagnosis
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Clinical:

  • Acute dermatitis (no fever, no lymphadenitis, itching)
  • initial zoster (important in differentiation from facial erysipelas; pain often dominant, no fever, no painful lymphadenitis, later path-breaking segmental spread with blister or blister formation)
  • superficial thrombophlebitis (string-like induration, fever is usually absent)
  • Lymphangitis acuta (characteristic linear redness along a lymphatic pathway)
  • Erysipelas carcinomatosum (mostly board-hard infiltration, lack of acuity)
  • Erysipeloid (infection runs blind, localization - hands),
  • Angioedema (no fever, no lymphadenitis)
  • Facial erysipelas
    • Rosacea erythematosa (chronic condition, no fever, intermittent redness and swelling)
    • Dermatomyositis/SLE (severe chronic clinical picture with adynamia and signs of an autoimmunological disease)
    • Acute dermatitis (detectable contact, acute within a few hours; vesicular dermatitis)
    • Angioedema (acute swelling, no fever, no lymphangitis, no pain)
    • Phlegmons
    • Thrombophlebitis
    • Erythema nodosum (highly painful plaques and nodules, usually no extensive redness)
    • Congestive dermatitis (in contrast to erysipelas, fever and pain are absent here)
    • Contact dermatitis (itchy erythema or plaques, in contrast to erysipelas always without fever)

Histological:

Complication(s)
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Therapy
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Systemic antibiosis see table 1.

Heparinization during bed rest. Antipyretic and, if necessary, analgesic measures with paracetamol (e.g. Ben-u-ron Tbl.) 3 times/day 500-1000 mg p.o.

In case of persistent swelling, manual and, if necessary, additional intermittent lymphatic drainage with apparatus from the 3rd-5th day after antibiosis.

Notice! No lymphatic drainage in acute inflammation! Germs are spread!

In case of recurrent erysipelas, treatment of acute symptoms, followed by regular penicillin cycles and lymphedema treatment for 1 year.

S.u. Erysipelas, recurrent.

General therapy
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Bed rest, cooling and elevation of the affected body part. After the acute inflammatory reaction has subsided, lymph drainage can be supportive. In the case of facial erysipelas, speaking is forbidden and the indication for passed fare exists.

External therapy
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Moist envelopes with antiseptic additives such as polihexanide (Serasept, Prontoderm), quinolinol solution(e.g. Chinosol 1:1000), R042 or potassium permanganate solution(light pink). Renew every 2 hours! Permanent and consistent rehabilitation of the entry portal (e.g. Tinea pedis).

Progression/forecast
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Under sufficient antibiotic therapy favorable. In case of predisposition (untreated tinea, lymphedema, chronic venous insufficiency) danger of recurrence. An existing underlying disease must be treated accordingly.

Tables
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System therapy for erysipelas

Pharmaceutical substance and sample preparation

Dose

Therapy duration

Uncomplicated course

Penicillin V (e.g. Megacillin)

1.5-3 million IU/day p.o. in 3-4 ED

10 days

Complicated course or chronic recurrence

Penicillin G (e.g. Penicillin Grünenthal)

15-30 million IU/day in 3-4 ED (max. 30 mega/day)

until healed

Complicated course/penicillin allergy

Vancomycin

40-60 mg/kg/day in 2-3 ED

until healed

Mixed infections

Oxacillin (e.g. Infectostaph)

4 times/day 1 g (max. 8 g) i.v. or i.m.

10 days

cephalosporins such as cefotaxime (e.g. claforan)

2-3 times/day 2 g i.v.

Until healing

Combination of cefuroxime (e.g. cefuroxime hexal) + gentamicin (e.g. refobacin)

2 times/day 1.5 g i.v. + 240 mg/day i.v.

Until healing

Penicillin allergy

Erythromycin (e.g. erythrocin)

4 times/day 0,5-1 g p.o.

10 days

Clarithromycin (e.g. Klacid)

2 times/day 250-500 mg p.o.

Literature
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  1. Brennecke S, Hartmann M, Schofer H, Rasokat H, Tschachler E, Brockmeyer NH (2005) Treatment of erysipelas in Germany and Austria--results of a survey in German and Austrian dermatological clinics. J Dtsch Dermatol Ges 3: 263-270
  2. Hadzovic-Cengic M et al.(2012) Cellulitis--epidemiological and clinical characteristics. Med Arch 66(3 Suppl 1):51-53
  3. Krasagakis K et al (2006) Bullous erysipelas: clinical presentation, staphylococcal involvement and methicillin resistance. Dermatology 212: 31-35
  4. Nayak N et al (2016) Clinical implications of microbial biofilms in chronic rhinosinusitis and orbital cellulitis
    .BMC Ophthalmol 16:165.
  5. Schwartz MN (2004) Cellulitis. N Eng J Med 350: 904-912
  6. Segnitz A et al (2010) Afebrile erysipelas under Etanercept. Nude Dermatol 35: 444-446
  7. Sunderkotter C, Herrmann M, Jappe U (2006) Antimicrobial therapy in dermatology. J Dtsch Dermatol Ges 4: 10-27

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

Authors

Last updated on: 29.10.2020