Assessment and

Management of Cellulitis
Ahmad amer
2020i-5a
 Cellulitis
Definition
“Non-necrotising
inflammation of the skin
and subcutaneous tissues,
usually caused by bacterial
infection”
 Pathophysiology
• Acute inflammation with heat, swelling, redness and pain.

• Microscopically: inflammatory infiltrate, predominant neutrophils and fat necrosis

• Erysipelas is superficial (only dermis), cellulitis involves subcutaneous tissues

Fig. 2 Eysipelas: high power H&E, Fig. 3 High power H&E,

Fig. 1 Eysipelas: low power H&E, inflammation
dense inflammatory infiltrate inflammation and fat necrosis

Images from DermNet NZ: https://www.dermnetnz.org/topics/erysipelas-pathology/

 Cellulitis
Clinical Presentation
Classic
• Erythema
• Pain
• Swelling
• Warmth
Signs suggestive of severe infection:
•Malaise, chills, fever, and toxicity
•Lymphangitic spread (red lines streaking
away from the area of infection)

•Circumferential cellulitis
• Pain disproportionate to examination
findings
 Cellulitis mimics
• Contact dermatitis

• Septic bursitis

• Gout
Fig. 1 Chronic lymphoedema changes

• Acute and chronic lipodermatosclerosis

(venous insufficiency)

• Lymphoedema

• BILATERAL cellulitis is rare

Fig. 2 Venous insufficiency changes
Images from DermNet NZ: https://www.dermnetnz.org/topics/erysipelas-pathology/
 Cellulitis RED FLAGS
•Violaceous bullae

•Cutaneous hemorrhage

•Skin sloughing

•Rapid progression

•Gas in the tissue

• Systemic compromise:
hypotension, tachycardia
 Necrotizing fasciitis
Life threatening emergency: skin, fat and muscle necrosis, polymicrobial, rapidly
progressive with shock, extensive tissue loss and death
 Pathogens
Erysipelas: skin raised above surrounding normal
skin, clear demarcation.
•Streptococcus pyogenes
•Common in infants, young children, older
adults.
•“Butterfly” pattern of facial skin, and affecting
lower limbs.

Cellulitis: Involves deeper tissues

• Children: periorbital
• Adults: lower legs
• Rapidly spreading: Streptococcus pyogenes
or other Streptococci e.g. group B, C, or G
• Trauma, ulceration: Staphylococcus aureus
(cMRSA, 40% of S.aureus)

Other organisms:
• Water related: Aeromonas spp., Vibrio spp.
• Immunocompromised: polymicrobial
including Gram negatives, fungi and
mycobacteria
 Predisposing factors
• Damage to skin e.g. trauma, ulcers.

• Tinea infection

• Fissured dermatitis

• Lymphoedema

• History of DVT

• Vascular surgery

• Radiotherapy

• Insect bites/scabies
 Diagnosis
Clinical, no investigations required if:

•Limited skin involvement

•Minimal pain

•No systemic signs of illness

(eg, fever, altered mental
status, tachycardia,
hypotension)

• No risk factors for serious

illness (eg, extremes of
age, co-morbidities
immunocompromise)
Systemic signs= Investigations

• FBP, CRP, U+E

• Blood cultures: Moderate to severe disease (cellulitis complicating lymphoedema)

•Orbital Cellulitis (fat and eye muscles) and periorbital (eyelid) cellulitis

•Patients with malignancy or chemotherapy

•Neutropenia or severe cell-mediated immunodeficiency

• Animal bites
 Hospital Admission
• Patients who have extensive cellulitis,
especially if:

• Patients with systemic signs (high

fever, chills, rigours, hypotension,
tachycardia)

• Immunocompromised

• Diabetics

• Chronic renal failure patients

• Orbital cellulitis (involvement of fat

and orbit muscles) +/- periorbital
cellulitis
 Treatment
• Mild: Streptococcus pyogenes, Staphylococcus aureus, use:

• Flucloxacillin 500mg (child 12.5mg/kg up to 500mg) QID orally

for 5-10 days

• Non-immediate penicillin allergy: Cephalexin 500mg (child

12.5mg/kg up to 500mg) QID orally for 5-10 days

• Immediate penicillin allergy: Clindamycin 450mg (child 10mg/kg

up to 450mg) TDS orally for 5-10 days

• Severe: Not improving after 48h or systemic symptoms

 Treatment
• Severe cellulitis management:

• Streptococcus pyogenes, Staphylococcus aureus, use:

• Flucloxacillin 2g (child 50mg/kg up to 2g) IV QID

• Non-immediate penicillin allergy: Cefazolin 2g (child 50mg/kg

up to 2g) IV TDS

• Immediate penicillin allergy: Vancomycin* or Clindamycin

600mg (child 15mg/kg up tp 600mg) IV TDS

***Ceftriaxone/broad spectrum antibiotics not required***

Therapeutic Guidelines Antibiotic, version 15, 2014

 Hospital in the Home
• Administration of IV antibiotics in outpatient setting where
IVABs are required for >1 week

• Once stable and select patients (independent, no significant co-

morbidities), supported home environment, able to attend clinic
reviews and blood testing.

• Antibiotic regimen: once daily dosing or infusion

• Requires log term IV line: PICC line

• Convenient for young/working individuals

• Nursing Service: Access via AMU, direct admit for adults

• SJOG Subiaco Hospital, ID Physicians and Health Choices

Nurses
 Cellulitis Take Home Messages
• Cellulitis is an infection of the
skin and subcutaneous tissues,
most common organisms
involved are S.pyogenes and
S.aureus

• RED FLAGS: systemic

symptoms, rapid progression, gas
in tissues, bullae,
immunocompromised patient,
orbital involvement
• Direct and fast admission to AMU at
• “Bilateral cellulitis” is rare, more SJOG Subiaco Hospital for IVABs and
likely venous insufficiency HITH without ED waiting times, expert
changes management and rapid return to work for
patients