with dermal lymphatic involvement. Diagnosis is clinical. Treatment is with oral or IV antibiotics.(See also Overview of Bacterial Skin Infections Overview of Bacterial Skin Infections Bacterial skin infections can be classified as skin and soft tissue infections (SSTI) and acute bacterial skin and skin structure infections (ABSSSI). SSTI include Carbuncles Ecthyma Erythrasma... read more .)
Erysipelas should not be confused with erysipeloid, a skin infection caused by Erysipelothrix Erysipeloid Erysipeloid is infection caused by the gram-positive bacillus Erysipelothrix rhusiopathiae. The most common manifestation is an acute but slowly evolving localized cellulitis. Diagnosis... read more 
.
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 characterized by shiny, raised, indurated, and tender plaque-like lesions with distinct margins.
Image provided by Thomas Habif, MD.
Note the sharp line of demarcation and bright red color, features that distinguish erysipelas from cellulitis.
© Springer Science+Business Media
This image shows the bullous form of erysipelas.
Image courtesy of Karen McKoy, MD.
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, Staphylococcus warneri, Streptococcus pneumoniae, Streptococcus pyogenes, and Moraxella species.
Erysipelas may be recurrent and may result in chronic lymphedema. Complications of erysipelas commonly include thrombophlebitis, abscesses, and gangrene.
Diagnosis of Erysipelas
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 Herpes Zoster Herpes zoster is infection that results when varicella-zoster virus reactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with pain along the affected... read more 
, angioedema Angioedema Angioedema is edema of the deep dermis and subcutaneous tissues. It is usually an acute but sometimes a chronic mast cell–mediated reaction caused by exposure to a drug (eg, angiotensin-converting... read more 
, and contact dermatitis Contact Dermatitis Contact dermatitis is inflammation of the skin caused by direct contact with irritants (irritant contact dermatitis) or allergens (allergic contact dermatitis). Symptoms include pruritus and... read more 
. Diffuse inflammatory breast cancer Symptoms and Signs Breast cancers are most often epithelial tumors involving the ducts or lobules. Most patients present with an asymptomatic mass discovered during examination or screening mammography. Diagnosis... read more 
may also be mistaken for erysipelas.
Treatment of Erysipelas
Oral or IV antibiotics
Antibiotics of choice for erysipelas include the following (1 Treatment reference Erysipelas is a type of superficial cellulitis with dermal lymphatic involvement. Diagnosis is clinical. Treatment is with oral or IV antibiotics. (See also Overview of Bacterial Skin Infections... read more 
):
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
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.
MRSA is not common in patients with erysipelas, and adding antibiotics to cover MRSA generally adds limited additional benefit. However, if MRSA is identified through culture or if MRSA is strongly suspected, an appropriate antibiotic such as clindamycin, trimethoprim/sulfamethoxazole, linezolid, doxycycline, or vancomycin can be added.
Bed rest and leg elevation are helpful for leg erysipelas. 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.
Treatment reference
1. Brindle R, Williams OM, Barton E, Featherstone P: Assessment of antibiotic treatment of cellulitis and erysipelas: A systematic review and meta-analysis. JAMA Dermatol 155(9):1033–1040, 2019. doi: 10.1001/jamadermatol.2019.0884
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).
Treat erysipelas with oral penicillin or, in penicillin-allergic patients, erythromycin; in severe cases, use parenteral penicillin or, in penicillin-allergic patients, ceftriaxone or cefazolin.
Treat methicillin-sensitive S. aureus infections with dicloxacillin, but treat suspected MRSA with oral clindamycin or trimethoprim/sulfamethoxazole or parenteral vancomycin or linezolid.
