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

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Erysipelas is a type of superficial cellulitis (see 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 plaque-like lesions with distinct margins. There is also a bullous form of erysipelas. Erysipelas is most often caused by group A (or rarely group C or G) β-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. Erysipelas of the face must be differentiated from herpes zoster, angioedema, and contact dermatitis. It is commonly accompanied by high fever, chills, and malaise; MRSA is more common in facial erysipelas than in lower-extremity erysipelas. Erysipelas may be recurrent and may result in chronic lymphedema.


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

Treatment of choice for lower-extremity erysipelas is penicillin V 500 mg po qid for 2 wk. In severe cases, penicillin G 1.2 million units IV q 6 h is indicated, which can be replaced by oral therapy after 36 to 48 h. An alternative parenteral therapy is ceftriaxone 1 g IV q 24 h or cefazolin 1 to 2 g IV q 8 h. Dicloxacillin 500 mg po qid for 10 days can be used for infections with staphylococci. Erythromycin 500 mg po qid for 10 days may be used in penicillin-allergic patients; however, there is growing macrolide resistance in streptococci. In infections resistant to these antibiotics, cloxacillin or nafcillin can be used. 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.

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