Merck Manual

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Wingfield E. Rehmus

, MD, MPH, University of British Columbia

Reviewed/Revised Jun 2023
Topic Resources

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.

Manifestations 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.

Other causes include 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

Treatment of Erysipelas

  • Oral or parenteral antibiotics

  • Penicillin V 500 mg every 6 hours

  • Amoxicillin 875 mg every 12 hours

  • Cephalexin 500 mg every 6 hours

  • Cefadroxil 500 mg every 12 hours or 1 g once a day

The 1st-line parenteral antibiotic (for severe cases) is parenteral aqueous crystalline penicillin G 4 million units IV every 4 hours. Alternative parenteral antibiotics are ceftriaxone 1 to 2 g IV once a day and cefazolin 1 to 2 g IV every 8 hours.

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 among patients with erysipelas, and adding antibiotics to cover MRSA adds limited additional benefit. However, if MRSA is identified through culture or if MRSA is strongly suspected, an appropriate antibiotic such as clindamycin, sulfamethoxazole/trimethoprim, doxycycline, linezolid, or vancomycin can be added. For methicillin-sensitive S. aureus infections, dicloxacillin may be used.

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 boots and compression socks) may also be of benefit for lower-extremity erysipelas.

Treatment reference

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).

  • 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.

  • Treat erysipelas with oral antibiotics that target streptococci, including penicillin, amoxicillin, cephalexin, or cefadroxil; in severe cases, use parenteral antibiotics such as penicillin; and in penicillin-allergic patients, use ceftriaxone or cefazolin.

  • Treat methicillin-sensitive S. aureus infections with dicloxacillin.

  • Treat suspected MRSA with clindamycin, sulfamethoxazole/trimethoprim, doxycycline, vancomycin, or linezolid.

Drugs Mentioned In This Article

Drug Name Select Trade
Beepen VK, Veetids
Amoxil, Dispermox, Moxatag, Moxilin , Sumox, Trimox
Biocef, Daxbia , Keflex, Keftab, Panixine
Ceftrisol Plus, Rocephin
Ancef, Kefzol
Cleocin, Cleocin Ovules, Cleocin Pediatric, Cleocin T, CLIN, Clindacin ETZ, Clindacin-P, Clinda-Derm , Clindagel, ClindaMax, ClindaReach, Clindesse, Clindets, Evoclin, PledgaClin, XACIATO
Primsol, Proloprim, TRIMPEX
Acticlate, Adoxa, Adoxa Pak, Avidoxy, Doryx, Doxal, Doxy 100, LYMEPAK, Mondoxyne NL, Monodox, Morgidox 1x, Morgidox 2x , Okebo, Oracea, Oraxyl, Periostat, TARGADOX, Vibramycin, Vibra-Tabs
Zyvox, Zyvox Powder, Zyvox Solution
FIRVANQ, Vancocin, Vancocin Powder, VANCOSOL
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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