Today we discussed an approach to cellulitis, and its mimickers. Some key points:
Cellulitis: acute, spreading pyogenic inflammation of dermis and subcutaneous tissue, sometimes complicating a wound, ulcer, or dermatosis. Lacks demarcation from uninvolved skin.
Erysipelas: superficial cellulitis with prominent lymphatic involvement, making peau d'orange appearance with raised border demarcated from uninvolved skin. Patients are often sicker.
Predisposing factors: saphenous vein harvesting, edema, mastectomy with lymph node dissection, liposuction, "skin popping" in IVDU
Source: portal of entry in skin (e.g. tinea pedis, ulcer)- by far most common; other possibilities include osteomyelitis, bacteremia.
Unusual sources: seawater (vibrio vulnificus), fresh water (aeromonas hydrophilia), fish (strep iniae)
Cellulitis in unusual areas:
Periorbital cellulitis: eyelid and periocular tissues anterior to orbital septum
Orbital: Involves extraocular muscles; predisposes to cavernous sinus thrombosis, decreased visual acuity.
Micro:
80% gram +ve (staph, strep), 20% gram -ve. Aspirates/swabs are not indicated (unless ulcer)
Broader coverage may be indicated in pts with DM2.
Blood cultures are indicated in lymphedema, buccal, periorbital, water exposure, chills or fever. Otherwise, bacteremia is rare (less than 4%).
Empiric treatment: Cefazolin or cephalexin. Other possibilities: cloxacillin, clindamycin, penicillin, amoxicillin-clavulin. May want broader coverage (e.g. gram -ve coverage) in diabetics
Ancillary measures: Elevation, immobilization. Interdigital dermatophytic infections should be treated (e.g. clotrimazole and miconazole), terbinafine, etc
Some cellulitis mimickers to consider (see link to paper below for more)
-stasis dermatitis (especially if bilateral)
-superficial thrombophlebitis (often with IV/catheter site)
-DVT
-contact dermatitis
-drug reaction (can be 'fixed'- i.e. single area)
-Sweet syndrome (neutrophilic dematosis- see previous post)
-gout (can cause erythema overlying joint- i.e. 'periarthritis')
Links:
Click here for excellent NEJM review of cellulitis that most of this post is based on
Click here for Annals of Internal Medicine review of cellulitis mimickers (common and uncommon)
Thanks for the information and the links to full text PDF articles.
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