Cellulitis

Infectious Diseases > Cellulitis

Summary
Description
 Cellulitis is a spreading, acute inflammation of the dermis and subcutaneous tissue, sometimes involving
muscle. There is considerable overlap in presentation between various skin and soft tissue infections, and many
have a cellulitic component. Hallmarks are erythema, edema, tenderness, and warmth
 Erysipelas, a streptococcal infection involving the superficial layers of the dermis, is characterized by a well-
demarcated raised area of vivid erythema; the more common appearance of cellulitis is one of varying degrees
of erythema and poorly defined margins. The degree of associated systemic illness is variable
 Cellulitis most frequently occurs on the head and neck in children, and the lower extremities in adults. Also
found on the scalp, the perianal area, or complicating surgical incisions, sites of chronic or traumatic
wounds, burns, or bites inflicted by animals or humans (including closed fist wounds)
 Patients most likely to develop cellulitis are those with diabetes (type 1 and type 2), immunodeficiency diseases,
previous cellulitis, venous and/or lymphatic compromise, alcoholism, intravenous drug abuse, and peripheral
vascular disease

Synonyms
Erysipelas (in common usage as a synonym, though technically used to refer to the unique presentation of
streptococcal infection described above).

Immediate action
 Check for signs of necrotizing infection: edema extending beyond area of erythema, bullae formation, skin
anesthesia, crepitus, discoloration affecting an entire limb or at a distant site on the same limb or elsewhere,
extremely toxic appearance of patient
 Immediate hospitalization and aggressive surgical management is required for necrotizing infection
 Rapid hospitalization is also required for deep and quickly spreading infections, particularly those on the face or
hand, and for patients with severe infection and systemic signs of sepsis (high fever or hypothermia,
tachycardia, hypotension)
 Hospitalization should be considered for patients with underlying disease, such as diabetes mellitus, severe
peripheral vascular disease, or immune dysfunction

Key points
 Cellulitis is a spreading, acute inflammation of the dermis and subcutaneous tissue, sometimes involving
muscle. Hallmarks are erythema, edema, tenderness, and warmth
 Risk factors include diabetes mellitus (type 1 and type 2), immunocompromised state, alcoholism, intravenous
drug abuse, and a prior history of cellulitis. A history of surgery resulting in disrupted lymphatic drainage
predisposes to recurrent episodes (eg, saphenous vein harvesting for coronary artery bypass grafting or
mastectomy and axillary node dissection)
 The infectious agent is most frequently Streptococcus pyogenes or Staphylococcus aureus
 First-line therapy includes oral antibiotics with good coverage of Gram-positive organisms
 Outpatients placed on oral antibiotic therapy should be re-evaluated 24 to 48 hours after starting therapy to
assess response to therapy
 Suspected necrotizing infection, deep or quickly spreading infection (particularly on the face and hands), and
orbital cellulitis require referral for further investigation and treatment

Background
Cardinal features
 Acute, spreading inflammation of the dermis and subcutaneous tissues
 Muscle may also be affected
 Affected areas are warm, red, edematous, and tender; there may be associated suppuration
 Lymphatic streaking and lymphadenopathy may be present
 Most frequently occurs on the head and neck in children, and lower extremities in adults. In intravenous drug
abusers, the upper extremities are often involved
 Can affect traumatic wounds, burns, animal bites, and surgical incisions
 Patients most frequently affected are those with diabetes (type 1 and type 2), immunodeficiency diseases,
previous cellulitis, venous, and/or lymphatic compromise,peripheral vascular disease, alcoholism, and
intravenous drug abuse
 The infectious agent is most frequently Streptococcus pyogenes or Staphylococcus aureus
 In the past, the most common infectious agent among children was Haemophilus influenzae, but since the
introduction of the Hib vaccine (H. influenzae type b), these infections are now less common

Causes
Common causes

 Group A β-hemolytic streptococci (Streptococcus pyogenes)

 Staphylococcus aureus
 Haemophilus influenzae (decreasing in frequency)
 Group B, C, D, or G β-hemolytic streptococci
Rare causes

Certain circumstances and host characteristics suggest infection with unusual organisms:
 Aerobic Gram-negative bacilli, including Escherichia coli and Pseudomonas aeruginosa (may occur with
granulocytopenia, diabetic foot ulcers, severe tissue ischemia, and institutionalized patients)
 Streptococcus agalactiae (patients with diabetes mellitus or peripheral vascular disease)
 Streptococcus pneumoniae (in peri-orbital cellulitis)
 Helicobacter cinaedi (patients with immune deficiency)
 Pasteurella multocida (cat and dog bites)
 Staphylococcus intermedius (dog bites)
 Capnocytophaga canimorsus (dog bites)
 Eikenella corrodens (animal bites and human bites)
 Bacteroides species (animal bites and human bites)
 Peptostreptococcus (human bites)
 Aeromonas hydrophila (injuries in freshwater lakes, rivers, and streams)
 Vibrio vulnificus (injuries in salt water; patients with certain forms of chronic liver disease are especially
susceptible and can develop rapidly progressive, life-threatening infection)
 Erysipelothrix rhusiopathiae (injuries from saltwater fish; also transmitted by farm animals)
 Pseudomonas aeruginosa (cellulitis involving the ear, including malignant otitis externa in diabetic patients and
infected cartilage piercings; also occurs in needlestick infections in intravenous drug users and may
complicate reptile bites. Commonly implicated in infections contracted by stepping on a nail while wearing a
sneaker; these infections frequently and rapidly evolve into osteomyelitis. “Hot-tub folliculitis” is a syndrome
 of folliculitis and cellulitis in the distribution of hot-tub immersion, caused by P. aeruginosa and associated
with inadequately cleaned hot-tubs)
 Mycobacterium marinum (injuries in aquariums or swimming pools)
 Mixed aerobic-anaerobic flora (suspected in synergistic necrotizing cellulitis)
 Enterobacteriaceae (suspected in intravenous drug users; common in cellulitis complicatingdiabetic
foot infections)
 Enterococcus (in diabetic foot infections and cellulitis associated with decubitus ulcers)
 Fungi, including mucormycosis and aspergillosis (suspected with immunocompromised hosts and intravenous
drug users)
 Atypical mycobacterium (suspected with immunocompromised hosts)
 Clostridium perfringens (may cause gas-forming cellulitis)
 Tuberculosis
 Syphilitic gumma
Serious causes

 Group A streptococci (several strains may cause severe infections leading to shock, multisystem organ failure,
and death)
 Haemophilus influenzae (may be associated with gas formation or purulent collections. In non-vaccinated
children younger than 3 years who lack an obvious portal of entry, meningitis should be considered)
 Clostridium perfringens (may cause gas gangrene if infection spreads to muscle)
 Mixed aerobic-anaerobic flora (suspected in synergistic necrotizing cellulitis)
 Vibrio vulnificus (can cause life-threatening infections in patients with certain forms of chronic liver disease)
 Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) can cause life-threatening
infection due to the virulence and rapid progression of necrosis and hemorrhage caused by the Panton-Valentine
leucocidin toxin
Contributory or predisposing factors

 Break in the skin due to trauma, puncture, laceration, animal bite, or sting
 Burns
 Skin lesions caused by furuncle, ulcer, or fungal infection (eg, tinea pedis)
 Surgical procedure or incision, including lymphadenectomy, saphenous vein stripping, and mastectomy
 Previous cellulitis
 Diabetes mellitus (type 1 and type 2)
 Lymphatic stasis
 Peripheral vascular disease
 Chronic steroid use
 Intravenous drug addiction
 AIDS or other immunodeficiency disorder
 Liver disease
 Renal failure
 Occupational exposure: farm workers; gardeners; handlers of fish, shellfish, and aquariums

Epidemiology
Incidence and prevalence

Frequency
Common in the U.S., but because it is a non-reportable infection, exact incidence is not known.
Demographics

Age
 Facial cellulitis usually occurs in adults aged 50 years or above, or children aged 6 months to 3 years
 Perianal cellulitis usually affects children
 Gender
 Perianal cellulitis is more common in male patients than in female patients
 No gender difference for other types of cellulitis
Geography
Cellulitis caused by halophilic Vibrio species occurs in coastal areas (shellfish handlers).
Socioeconomic status
 Immigrant populations who may not have been vaccinated against Haemophilus influenzaetype b and tetanus
are at increased risk of infection
 Overcrowded conditions may also exacerbate infection
 Farm, garden, fish, and shellfish workers are at increased risk of infection by rare agents causing cellulitis

Codes
ICD-9 code

 376.01 Orbital cellulitis

 681.00 Cellulitis and abscess of finger and toe; finger; cellulitis and abscess, unspecified
 681.10 Cellulitis and abscess of finger and toe; toe; cellulitis and abscess, unspecified
 681.9 Cellulitis and abscess of finger and toe; cellulitis and abscess of unspecified digit, infection of nail NOS
 682.0 Cellulitis and abscess; face
 682.1 Cellulitis and abscess; neck
 682.2 Cellulitis and abscess; trunk
 682.3 Cellulitis and abscess; upper arm and forearm
 682.4 Cellulitis and abscess; hand, except fingers and thumb
 682.5 Cellulitis and abscess; buttock
 682.6 Cellulitis and abscess; leg, except foot
 682.7 Cellulitis and abscess; foot, except toes
 682.8 Cellulitis and abscess; other specified sites
 682.9 Cellulitis and abscess; unspecified site

More Key Resources

Overview
Cellulitis and Superficial Infections (includes Table)
Mandell: Principles & Practice of Infectious Diseases, 7th ed.
Cellulitis (Quick Reference)
Ferri: Ferri's Clinical Advisor 2013, 1st ed.
Cellulitis
Ferri: Practical Guide to the Care of the Medical Patient, 8th ed.
Cellulitis
Walsh: Palliative Medicine, 1st ed.
Cellulitis (includes Table)
Rakel: Textbook of Family Medicine, 8th ed.
Cellulitis (includes Image)
Long: Principles & Practice of Pediatric Infectious Diseases, 3rd ed., Revised Reprint
Cellulitis (includes Images)
Marks: Lookingbill and Marks' Principles of Dermatology, 4th ed.
Cellulitis
Adams: Emergency Medicine, 1st ed.

Epidemiology
Epidemiology and Demographics of Cellulitis
Ferri: Ferri's Clinical Advisor 2013, 1st ed.
Epidemiology of Cellulitis
Bergelson: Pediatric Infectious Diseases: Requisites, 1st ed.
Signs & Symptoms
Cellulitis of Specific Areas (includes Images)
Habif: Clinical Dermatology, 5th ed.
Clinical Findings of Cellulitis (includes Tables)
Mandell: Principles & Practice of Infectious Diseases, 7th ed.
Clinical Presentation of Cellulitis
Tyring: Tropical Dermatology, 1st ed.
Clinical Features of Cellulitis
Sun: The Most Common Inpatient Problems in Internal Medicine: Ward Survival, 1st ed.
Clinical Features of Cellulitis (includes Images)
Weston: Color Textbook of Pediatric Dermatology, 4th ed.
Clinical Features of Cellulitis (includes Images)
Cohen and Powderly: Infectious Diseases, 3rd ed.

Etiology
Etiology of Cellulitis
Ferri: Ferri's Clinical Advisor 2013, 1st ed.
Pathogenesis of Cellulitis
Weston: Color Textbook of Pediatric Dermatology, 4th ed.
Etiology of Cellulitis
Kliegman: Nelson Textbook of Pediatrics, 19th ed.
Etiology of Preseptal Cellulitis
Bergelson: Pediatric Infectious Diseases: Requisites, 1st ed.

Diagnosis
Diagnosis of Cellulitis
Habif: Clinical Dermatology, 5th ed.
Skin and soft tissue infections in older adults
Anderson DJ - Clin Geriatr Med - 01-AUG-2007; 23(3): 595-613, vii
Diagnosis of Cellulitis (includes Image)
Feigin: Feigin and Cherry's Textbook of Pediatric Infectious Diseases, 6th ed.
Diagnosis of Cellulitis
Schwarzenberger: General Dermatology, 1st ed.

Treatment & Management

Skin and soft tissue infections
May AK - Surg Clin North Am - 01-APR-2009; 89(2): 403-20, viii
Treatment of Cellulitis
Tyring: Tropical Dermatology, 1st ed.
Empirical Treatment of Cellulitis
Bergelson: Pediatric Infectious Diseases: Requisites, 1st ed.
Antibiotic Treatment of Cellulitis
Cohen and Powderly: Infectious Diseases, 3rd ed.
Treatment of Cellulitis
Walsh: Palliative Medicine, 1st ed.
Nonpharmacologic Therapy of Cellulitis
Garfunkel: Pediatric Clinical Advisor, 2nd ed.

Prognosis
Disposition of Cellulitis
Garfunkel: Pediatric Clinical Advisor, 2nd ed.

Screening & Prevention

Prevention of Cellulitis
Garfunkel: Pediatric Clinical Advisor, 2nd ed.
Prevention of Orbital Cellulitis
Zaoutis: Comprehensive Pediatric Hospital Medicine, 1st ed.

Patient Education
 Managing Your Cellulitis

Practice Guidelines
Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections (2005)
Source: Infectious Diseases Society of America

Drugs
 Amoxicillin; Clavulanic Acid
 Ampicillin; Sulbactam
 Ciprofloxacin
 Clindamycin
 Moxifloxacin