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Snapshot
  • A 60-year-old man with a past medical history of diabetes and hypertension presents with swelling in his right leg after he scraped his calf on the corner edge of his coffee table. On physical exam, there is a poorly demarcated 10 cm red and tender plaque on his right calf. Some parts resemble an orange peel. There is a superficial scrape in the middle of the plaque. He is sent home on oral antibiotics.
Introduction
  • Clinical definition
    • painful bacterial infection involving the deeper dermis and subcutaneous tissues
      • often from Streptococcal spp. or, less commonly, S. aureus
    • from superficial involvement of skin to deep
      • impetigo (very superficial skin infection)
      • erysipelas (upper dermis and cutaneous lymphatics)
      • cellulitis (deeper dermis and subcutaneous tissues)
  • Epidemiology
    • incidence
      • 48 per 1000 person-years
    • risk factors
      • skin ulcers
      • tinea pedis
      • intravenous drug use
      • venous insufficiency
      • diabetes
      • lymphedema
      • pre-existing skin injury
  • Etiology
    • streptococcus species
    • S. aureus
  • Pathogenesis
    • pre-existing injury in skin can act as entry portal for bacteria
  • Prognosis
    • recurrence
Presentation
  • Symptoms
    • painful and tense skin
  • Physical exam
    • fever
    • diffuse inflammation of affected area
      • poorly demarcated
      • red
      • warm
      • tender
      • dimpling around hair follicles resembling orange peel (peau d’orange)
    • may have purulence
Evaluation
  • Labs
    • tissue cultures
      • may aid diagnosis and guide treatment
    • blood cultures
      • if cellulitis is purulent
  • Diagnosed clinically
Differential
  • Erysipelas
    • more superficial involvement of skin and soft tissues
    • there is often an overlap and may not be distinguished clinically from erysipelas
Treatment
  • Medical
    • oral antibiotics
      • indications
        • for mild cases of cellulitis
      • drugs
        • penicillin
        • dicloxacllin
        • cephalexin
        • clindamycin
          • for suspected methicillin-resistant S. aureus
    • IV antibiotics
      • indications
        • for cellulitis with signs of systemic infection
          • e.g., positive blood cultures
      • drugs
        • penicillin
        • cefazolin
        • ceftriaxone
        • clindamycin
Complications
  • Skin abscess formation
    • more common in IV drug users
  • Lymphedema
    • due to lymphatic damage caused by infection
    • may be permanent
  • Sepsis
 

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