Erysipelas: Causes, Symptoms and Treatment

What is Erysipelas?

Erysipelas is an acute infection of the upper layers of the skin and the superficial lymphatic vessels. It is one of the most common bacterial skin infections and can affect people of all ages, though it most frequently occurs in older adults, people with diabetes, and those with weakened immune systems. When treated promptly, erysipelas generally responds well to antibiotic therapy.

Causes

Erysipelas is caused in the vast majority of cases by beta-hemolytic Group A streptococci (Streptococcus pyogenes). Less commonly, staphylococci or other bacteria may be responsible. The pathogens enter the body through small skin breaks, cracks, fungal infections (such as athlete's foot), chronic wounds, or areas of inflammation.

Risk factors that increase susceptibility include:

• Chronic lymphedema or venous insufficiency
• Diabetes mellitus
• Immunosuppression (due to medications or underlying conditions)
• Obesity
• Compromised skin barrier or poor skin hygiene
• Previous episodes of erysipelas (high recurrence risk)

Symptoms

Erysipelas typically begins abruptly and can progress rapidly within hours. The hallmark feature is a sharply demarcated, bright red, warm, and swollen area of skin that spreads in a flame-like pattern and is tender to the touch.

Common symptoms include:

• Sudden onset of a shiny, bright red skin rash with clearly defined, irregular borders
• Local swelling and warmth
• Pain and tenderness in the affected area
• Systemic symptoms: high fever (often above 39 degrees Celsius), chills, fatigue, and headache
• Swollen lymph nodes near the site of infection
• In severe cases: blistering (bullous erysipelas), hemorrhagic discoloration, or tissue necrosis

The most commonly affected sites are the lower legs and the face, where the infection may spread across the nose bridge in a butterfly distribution.

Diagnosis

Erysipelas is primarily diagnosed clinically, based on the characteristic appearance of the skin and the associated systemic symptoms. Additional diagnostic tools may include:

• Blood tests: Elevated inflammatory markers (CRP, white blood cell count, ESR) confirm active infection.
• Blood cultures: Taken in severe or complicated cases to identify the causative organism.
• Wound swabs: Collected from open entry wounds for bacterial identification.
• Ultrasound: Used to rule out deeper tissue infections such as abscess, phlegmon, or necrotizing fasciitis.

It is important to differentiate erysipelas from other conditions such as deep vein thrombosis, cellulitis, contact dermatitis, or necrotizing fasciitis, as the latter is a life-threatening emergency requiring immediate surgical intervention.

Treatment

Antibiotic Therapy

The primary treatment for erysipelas is antibiotic therapy. The first-line agents are penicillins (e.g., oral phenoxymethylpenicillin or intravenous benzylpenicillin in severe cases). For patients with penicillin allergy, cephalosporins or clindamycin are suitable alternatives. The typical treatment duration is 10 to 14 days.

Supportive Measures

• Elevation of the affected limb to reduce swelling
• Cool, moist compresses to relieve pain and heat
• Bed rest when systemic symptoms are pronounced
• Treatment of the entry site (e.g., antifungal therapy for athlete's foot)

Inpatient Care

Severe cases, patients with significant fever, complications, or those who are immunocompromised may require hospital admission for intravenous antibiotic therapy and close monitoring.

Prevention of Recurrence

In patients with frequent recurrences (more than two episodes per year), long-term prophylactic antibiotic therapy (e.g., with oral penicillin V or monthly benzathine penicillin injections) may be considered. Consistent treatment of the underlying entry wound or skin condition is equally important.

Complications

Without adequate treatment, erysipelas can lead to serious complications, including:

• Abscess formation or phlegmon (deep tissue infection)
• Necrotizing fasciitis (life-threatening deep infection)
• Sepsis (bloodstream infection)
• Chronic lymphedema as a result of repeated episodes
• Post-streptococcal complications (rare)

References

1. Sunderkötter C. et al. – Skin and Soft Tissue Infections Caused by Streptococci and Staphylococci. Dtsch Arztebl Int. 2019;116(45):764-771.
2. Stevens D.L. et al. – Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections. Clinical Infectious Diseases. 2014;59(2):147-159.
3. World Health Organization (WHO): Skin and soft tissue infections – clinical management guidelines. WHO Publications, Geneva.