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By A. Damian Dhar, MD, JD, Private Practice, North Atlanta Dermatology

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Patient Education

Erysipelas is a type of superficial cellulitis with dermal lymphatic involvement.

Erysipelas should not be confused with erysipeloid, a skin infection caused by Erysipelothrix (see Erysipelothricosis). 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 sp. MRSA is more common in facial erysipelas than in lower-extremity erysipelas.

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


  • Clinical evaluation

  • Blood culture

Diagnosis 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 carcinoma of the breast 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 po qid for ≥ 2 wk

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

  • First-line parenteral therapy (for severe cases): Penicillin G 1.2 million units IV q 6 h, followed by oral therapy after 36 to 48 h

  • Alternative parenteral therapy (eg, for penicilin-allergic patients): Ceftriaxone 1 g IV q 24 h or cefazolin 1 to 2 g IV q 8 h

  • Infections with methicillin-sensitive Staphylococcus: Dicloxacillin 500 mg po qid for 10 days

  • Infections resistant to other antibiotics: Cloxacillin or nafcillin

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 q 12 h (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.

Key Points

  • MRSA is more common in facial erysipelas than in lower-extremity erysipelas.

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

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

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