MSD Manual

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A. Damian Dhar

, MD, JD, North Atlanta Dermatology

Last full review/revision Sep 2019| Content last modified Sep 2019
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Erysipelas is a type of superficial cellulitis with dermal lymphatic involvement. Diagnosis is clinical. Treatment is with oral or IV antibiotics.

Erysipelas should not be confused with erysipeloid, a skin infection caused by Erysipelothrix.

Erysipelas is characterized clinically by shiny, raised, indurated, and tender plaques with distinct margins. High fever, chills, and malaise frequently accompany erysipelas. There is also a bullous form of erysipelas.

Erysipelas is most often caused by group A (or rarely group C or G) beta-hemolytic streptococci and occurs most frequently on the legs and face. However, other causes have been reported, including Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]), Klebsiella pneumoniae, Haemophilus influenzae, Escherichia coli, S. warneri, Streptococcus pneumoniae, S. pyogenes, and Moraxella species. MRSA is more common in facial erysipelas than in lower-extremity erysipelas.

Erysipelas may be recurrent and may result in chronic lymphedema. Complications of erysipelas commonly include thrombophlebitis, abscesses, and gangrene.


  • Clinical evaluation

  • Blood culture

Diagnosis of erysipelas is by characteristic appearance; blood culture is done in toxic-appearing patients.

Erysipelas of the face must be differentiated from herpes zoster, angioedema, and contact dermatitis. Diffuse inflammatory breast cancer may also be mistaken for erysipelas.


  • Usually penicillin for lower-extremity erysipelas

  • Initially vancomycin for facial erysipelas or if MRSA is suspected

Antibiotics of choice for lower-extremity erysipelas include the following:

  • Routine, first-line oral therapy: Penicillin V 500 mg 4 times a day for ≥ 2 weeks

  • Alternative oral therapy (eg, for penicillin-allergic patients): Erythromycin 500 mg 4 times a day for 10 days (however, macrolide resistance in streptococci is growing)

  • First-line parenteral therapy (for severe cases): Penicillin G 1.2 million units IV every 6 hours, followed after 36 to 48 hours by oral therapy with penicillin V 500 mg 4 times a day

  • Alternative parenteral therapy (eg, for penicillin-allergic patients): Ceftriaxone 1 g IV every 24 hours or cefazolin 1 to 2 g IV every 8 hours, followed after 36 to 48 hours by oral therapy with erythromycin 500 mg 4 times a day for 5 to 10 days

  • Infections with methicillin-sensitive S. aureus: Dicloxacillin 500 mg orally 4 times a day for 10 days

  • Infections resistant to other antibiotics: Cloxacillin or nafcillin

Duration of treatment is based mainly on clinical response rather than a fixed interval.

In Europe, pristinamycin and roxithromycin have been shown to be good choices for erysipelas.

If facial erysipelas is present or if MRSA is suspected, empiric therapy should be initiated with vancomycin 1 g IV every 12 hours (which is active against MRSA).

Cold packs and analgesics may relieve local discomfort. Fungal foot infections may be an entry site for infection and may require antifungal treatment to prevent recurrence. Compression therapy (using, for example, Unna paste boots and compression socks) may also be of benefit for lower-extremity erysipelas.

Key Points

  • Consider erysipelas with shiny, raised, indurated, and tender plaques that have distinct margins, particularly if there are systemic signs (eg, fever, chills, malaise).

  • Methicillin-resistant S. aureus (MRSA) is more common in facial erysipelas than in lower-extremity erysipelas.

  • Consider penicillin for lower-extremity erysipelas and initially vancomycin if MRSA is suspected or for facial erysipelas.

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