Cellulitis

Definition/Description

Cellulitis is a localized bacterial skin infection, which typically affects the lower limbs but can occur on any area of skin and underlying subcutaneous tissue. It is characterized by acute onset of redness, inflammation, pain, and swelling of the affected area. Accompanying symptoms include generalized fever, rigors, nausea, and vomiting.[1]

The infection is most commonly caused by B-Hemolytic Streptococci bacteria and reoccurs up to 50% of the time in the lower extremity.[2] Most individuals diagnosed with cellulitis have a low risk of severe complications but few sufferers can have severe sepsis, local gangrene, and/or necrotizing fasciitis.[1]

Mild cellulitis.jpg
A mild case of cellulitis[3]
Severe cellulitis.jpg
A severe case of cellulitis that developed under a cast[3]

Prevalence

  • 650,000 hospital admissions per year in the United States are due to cellulitis.[4]
  • When hospitalized, patients with recurrent cellulitis require longer hospitalizations relative to nonrelapsing cellulitis patients.[4]
  • From 1998-2006, 10% of all infectious-disease hospitalizations were related to cellulitis[4]
  • 22-49% of patients who have cellulitis report at least one previous episode[4]
  • Recurrences, typically in the same location, occur approximately 14% of cellulitis cases within 1 year and in 45% of cases within 3 years[4]

Characteristics/Clinical Presentation

Typical symptoms include acute poorly demarcated and spreading erythema along with pain, swelling, and warmth of the lower extremity but can occur on any area of skin or underlying subcutaneous tissue.[2][4] Additional symptoms may include fever, nausea, vomiting, and rigors.[4][5] Other features include proximal dilated and edematous skin lymphatics and bulla formation. Cellulitis predominantly has a unilateral presentation, most commonly in the lower extremity.[4]

Classic celulitis.PNG
A classic presentation of cellulitis: poorly demarcated erythema[6]

Associated Co-morbidities

Diabetes Mellitus is one of most common comorbidities among those hospitalized for acute bacterial infections including cellulitis.
Following a cellulitis infection, those with diabetes require a longer course of antibiotic therapy and are more likely to have an outpatient follow-up visit.[7]

Lymphatic flow changes can predispose individuals to a cutaneous infection. Examples of co-morbidities that result in lymphatic flow changes include peripheral vascular disease, liposuction, radiation therapy, lymph node dissection, and lymphedema.[8]

Medications

Cephalexin, Dicloxacillin, Penicillin VK, Amoxicillin, and Clindamycin are typical Antistreptococcal Antimicrobial agents for the treatment of typical cellulitis that is considered mild and does not show signs of systemic involvement.[4]

Table 1 indicates which medications would be appropriate based on the severity of symptoms and the risk of Methicillin-resistant Staphylococcus aureus (MRSA).

Table 1
Clinical Presentation Appropriate Antibiotic Treatment
Routine Cellulitis with low suspicion of MRSA Dicloxacillin, Cephalexin, Nafcillin, or Cefazolin
High suspicion of MRSA or Penicillin allergy Doxycyline, Clindamyciin, Trimethoprim-sulfamethoxazole
High suspicion of MRSA with signs and symptoms of severe infection or patient did not respond to intitial routine treatment Vancomycin♦, Linezolid

♦Vancomycin is the preferred treatment for MRSA[4]

Diagnostic Tests/Lab Tests/Lab Values

Cultures are typically not beneficial in making a cellulitis diagnosis. It is most commonly diagnosed by history and physical examination alone. Certain laboratory tests can indicate the presence of infection, but are not specific to cellulitis alone. Elevated white blood cell count, C-reactive protein, and erythrocyte sedimentation rate are the most common laboratory results in people with cellulitis, though the prevalence of these results varies widely on a case by case basis
Imaging studies can identify more severe infections to differentiate from cellulitis, but are not a reliable diagnostic tool for cellulitis itself.[4]

Identification of the cause of the infection through blood, needle aspiration or punch biopsy are not recommended unless the patient has a complication or abnormal exposure history. This would include immunosuppressants, a diagnosis of chronic liver disease, aquatic soft tissue injury, animal and human bites, or being in contact with various bacterias.[4]

If a biopsy and culture are warranted, a histopathologic evaluation will be performed on the sample. Hematoxylin-and-eosin and certain stainings for organisms, bacteria, fungi, and microbacteria will be included.[9]

Etiology/Causes

Cellulitis can be caused by various organisms but most commonly by Streptococcus pyogenes or Staphylococcus aureus.[10] The organisms may enter the body after a cut, bite, or wound that compromises the skin or may enter through microscopic changes in the skin. They enter the dermis and multiply to cause cellulitis.

Studies show lymphedema is a major risk factor for the development of cellulitis. There is known to be a link between the two, but it is not known which of the two comes first. Patients with lymphedema or chronic edema are more prone to infection due to damage to lymphatic vessels and immune deficiency in that area. Cellulitis on the other hand, can cause damage to the lymphatics and the development of lymphedema.[8]

Cellulitis and lymphedema.JPG
[8]

Systemic Involvement

Cellulitis can be found anywhere on the skin, and can cause systemic issues in those areas. Locally, cellulitis often results in significant tissue damage in the involved area.[4] Cellulitis can spread systemically through the lymphatics and blood stream, which can lead to further complications.[3] If cellulitis does spread systemically through one of these systems, it can cause flu-like symptoms such as fever, rigors, nausea, and vomiting.[5][8] Though rare, there is a risk for severe sepsis, gangrene, or necrotizing fasciitis if cellulitis spreads systemically and is left untreated.[5]

Cellulitis Mayo.PNG
[11]

Medical Management (Current Best Evidence)

Currently, there are no published national guidelines for the treatment of cellulitis.

Although there are no national guidelines, there are two classification systems based on expert opinion that may be used. The Eron Classification system is the most widely used and is described in Table 2[12]. A more recent classification system, The Dundee Classification, was released in 2010. Table 3 compares these two classification systems based on strength of evidence, validation, and criteria.[12]

Most common management of the infection is administration of antibiotics. In more severe cases of cellulitis, intravenous antibiotics can be used.[9] Elevation and compression of the affected area promotes drainage of edema and can reduce inflammation, speeding up recovery.[9]

For those with recurrent cellulitis, prophylactic antibiotic therapy is an option. Recent studies show that antibiotic prophylaxis substantially reduced the number or recurrences experienced by patients while actively taking the medication. Although there is reduction during the antibiotic therapy, there is no evidence of persistent protect effect after it has ceased.[1]

Below is a treatment algorithm for Non-purulent Cellulitis, as described by Raff et. al.[4]

Medicalmanagementcellulitis.jpg
Table 2: Eron Clinical Classification System
Class Systemic toxicity Comorbidities Oral v intravenous antibiotics Outpatient v hospital admission
1 No sign None Oral Outpatient
II May or may not have systemic illness Peripheral vascular disease,

obesity, venous insufficiency

Intravenous Hospital admission for 48 hours then

outpatient parenteral antibiotic therapy

III Significant systemic toxicity—confusion,

tachycardia, tachypnoea, hypotension

Unstable Intravenous Hospital
IV Sepsis syndrome/necrotizing fasciitis Unstable Intravenous with or without surgical debridement Hospital
Table 3: Eron classification v Dundee classification
Parameter Eron (2003) Dundee (2010)
Strength of evidence Expert opinion Retrospective study of 205 consecutive patients
Incorporated into guidelines? CREST and NHS acute trusts NA
Validated? Yes Yes
Criteria Comorbidities including obesity and peripheral vascular

disease

The importance of comorbidities
Systemic toxicity: pyrexia (>38ºc), hypotension, tachypnoea,

and tachycardia

Obesity and peripheral vascular disease not counted towards hospital

admission

Up to date definition of systemic inflammatory response syndrome (SIRS)
Standardised and validated early warning scores


Physical Therapy Management (Current Best Evidence)

While there is lack of evidence that discusses specific physical therapy interventions for cellulitis, therapists should be aware of the signs and symptoms in order to refer the patient appropriately. Physical therapists should have awareness of risk factors and various causes of cellulitis, in addition to signs and symptoms.

According to some references, there are some modalities that physical therapists can use for a patient with cellulitis. Rest and elevation of the affected limb is important and can help alleviate pain. The application of cool, wet, sterile bandages is also recommended for pain relief, and ice can be used as well. Massage to promote lymphatic drainage, may help prevent cellulitis, particularly when used in conjunction with compression and exercise. However, it should not be used during an active cellulitis infection.[13]

Differential Diagnosis

Common differential diagnoses for Cellulitis include Deep Vein Thrombosis, Dermatitis, and Erythema Migrans. A description of these and additional diagnoses are described in Table 4[6]

A diagnosis other than Cellulitis can be due to infectious, inflammatory, vascular or neoplastic conditions. These are discussed in Table 5.[4]

Common Differential Diagnoses of Cellulitis - Table 4
Erythema Migrans Commonly caused by tick bite; presents as “bullseye” rash on skin; can be due to recent travel to NE, NW, or Upper Midwest US, and certain parts of Canada, Europe, and Asia
Deep Vein Thrombosis Suspected if certain risk factors present (examples include: family history, active cancer treatment), positive compression ultrasound test, D-dimer test results would be elevated
Stasis Dermatitis Would present bilaterally; may have hyperpigmentation changes; commonly seen over medial malleoli; responds well to compression, elevation, and steroid use
Contact Dermatitis Would present with pruritus and noticeable skin reaction; would likely have a report of exposure to a skin irritant
Other possible classifications for differential diagnoses - Table 5
Infectious Herpes zoster virus; Herpes simplex; skin ulcers
Inflammatory Gout; drug reactions; angioedema; acute bursitis
Vascular Lymphedema; hematoma; thrombophlebitis
Neoplastic (uncommon) Lymphoma; Leukemia; Paget disease of the breast; inflammatory carcinoma of the breast
Other Insect bites; adverse reaction to implant (examples include metal, mesh, or silicone)


Resources

Patient Resources:

American Academy of Dermatology tips for avoiding recurrance of Cellulitis:[14]

  1. Avoid injuring your skin
  2. Treat wounds right away
  3. Keep your skin clean and moisturized
  4. Keep your nails well-manicured
  5. Do not have blood drawn in an arm that has had cellulitis
  6. Treat infections promptly
  7. Treat other medical conditions
  8. Treat lymphedema
  9. Lose weight
  10. Stop Smoking
  11. If you drink alcohol, drink in moderation
  12. Check your feet every day to see if you have an injury or infection
Cellulitis prevention.JPG
[14]

Healthcare Provider Resources:

The following video link by dermatologist Dr. Noah Craft MD, PhD, DTMH discusses Cellulitis from the provider point of view and includes case studies, differential diagnosis, and treatment approaches.

https://www.youtube.com/watch?v=ZkntcZt0aho&feature=youtu.be

References

  1. 1.0 1.1 1.2 Mason JM, Thomas KS, Crook AM, Foster KA, Chalmers JR, et al. Prophylactic Antibiotics to Prevent Cellulitis of the Leg: Economic Analysis of the PATCH I and II Trials. PLoS ONE. 2014;9(2):e82694 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0082694 (accessed 28 Feb 2017).
  2. 2.0 2.1 Tsai C-YL, Calvin MK, Chung C, Susan Shin-Jung L, Yao-Shen C, Hung C. Development of a prediction model for bacteremia in hospitalized adults with cellulitis to aid in the efficient use of blood cultures: a retrospective cohort study. BMC Infectious Diseases. 2016;16(1):581.
  3. 3.0 3.1 3.2 Medscape. Cellulitis. http://emedicine.medscape.com/article/214222-overview (accessed 27 Feb 2017).
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016;316(3):325-37. http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/935437/ (accessed 27 Feb 2017).
  5. 5.0 5.1 5.2 Kilburn SA, Featherstone P, Higgins B, Brindle R. Interventions for cellulitis and erysipelas. (Cochrane review). Cochrane Database Syst Rev. 2010(6):CD004299.
  6. 6.0 6.1 Bailey E, Kroshinsky D. Cellulitis: Diagnosis and Management. Dermatologic Therapy. 2011;24:229–39.http://onlinelibrary.wiley.com/doi/10.1111/j.1529-8019.2011.01398.x/full (accessed 15 Mar 2017).
  7. Jenkins TC. Comparison of the Microbiology and Antibiotic Treatment among Diabetic and Non-Diabetic Patients Hospitalized for Cellulitis or Cutaneous Abscess. J Hosp Med. 9ADADDec12;:788–94.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4256165/ (accessed 28 Feb 2017).
  8. 8.0 8.1 8.2 8.3 Riches K, Keeley V. Cellulitis in patients with chronic oedema. Nursing & Residential Care [serial on the Internet]. (2012, Mar), [cited March 31, 2017]; 14(3): 122-127. Available from: CINAHL with Full Text.
  9. 9.0 9.1 9.2 McNamara DR, Tleyjeh IM, Berbari EF, Lahr BD, Martinez J, Mirzoyev SA, Baddour LM. A predictive model of recurrent lower extremity cellulitis in a population-based cohort. Arch Intern Med. 2007;167(7):709-715 http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/412163 (accessed 15 March 2017)
  10. Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. BMJ [Internet]. 2012Jul [cited 2017Mar20];345(aug07 2):38–42. Available from: http://www.bmj.com/bmj/section-pdf/187604?path=/bmj/345/7869/Clinical_Review.full.pdffckLRMedscape. Cellulitis. http://emedicine.medscape.com/article/214222-overview (accessed 27 Feb 2017).
  11. Cellulitis [Internet]. Mayo Clinic. [cited 2017Apr4]. Available from: http://www.mayoclinic.org/diseases-conditions/cellulitis/basics/definition/con-20023471
  12. 12.0 12.1 Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. BMJ [Internet]. 2012Jul [cited 2017Mar20];345(aug07 2):38–42. Available from: http://www.bmj.com/bmj/section-pdf/187604?path=/bmj/345/7869/Clinical_Review.full.pdffckLRMedscape. Cellulitis. http://emedicine.medscape.com/article/214222-overview (accessed 27 Feb 2017).
  13. University of Maryland Medical Center. http://umm.edu/health/medical/altmed/condition/cellulitis (accessed 25 March 2017).
  14. 14.0 14.1 Cellulitis [Internet]. Cellulitis | American Academy of Dermatology. [cited 2017Mar24]. Available from: https://www.aad.org/public/diseases/rashes/cellulitis