A swollen, red, warm, hardened and painful rash with sharply demarcated advancing margins that can appear on the face and spreads across the cheeks and bridge of the nose. Rash onset occurs after an initial 48-hour period in which symptoms including high fever, shaking, chills, fatigue, headaches and vomiting develop. The patient’s lymph nodes may be swollen. What’s your diagnosis?
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Erysipelas is an acute bacterial infection of the skin and subcutaneous tissue in which the Streptococcus pyogenes bacterium invade tissue via a sore or wound. The young and the elderly are the most commonly affected. The disorder starts abruptly with fever, headaches and vomiting. Erythema appear on the face and spread across the cheeks and bridge of the nose. Within the inflamed area, pimples develop that blister, burst and crust over.
Historically erysipelas occurred on the face, but it is increasingly being identified on extremities such as the arms and legs. Approximately 85% of cases now occur on the legs. Non-group A streptocci have also been identified as etiologic agents.
Portals of entry may include stasis ulcerations, inflammatory dermatoses, dermatophyte infections, insect bites, and surgical incisions.
No work up is needed to identify erysipelas, except in imunnosupressed patients, as routine blood and tissue cultures have low yields and are not cost effective.
First-line therapy is oral or intramuscular penicillin administered for 10 to 20 days. If a patient is allergic to penicillin, a first generation cephalosporin or macrolide are appropriate alternatives. Caution should be used prescribing cephalosporin to patients with a history of severe anaphylactic reactions to penicillin.
If erysipelas does not resolve after first-line antibiotic treatment, clinicians may want to consider prescribing a drug with coverage against Staphylococcus aureus such as dicloxacillin or nafcillin; however, minimal evidence exists to support this recommendation.
In severe cases with necrosis and gangrene, clinicians may consider surgical debridement. Patients with recurrent erysipelas should be counseled regarding general wound care.