Abstract
Erysipelas and uncomplicated cellulitis are common infections that tend to recur in a substantial proportion of affected patients following an initial episode, especially if the predisposing condition is chronic lymphedema. All patients who suffer an episode of cellulitis should be carefully evaluated to establish the risk of recurrence. Several predisposing conditions (such as lymphedema and skin conditions that serve as a portal of entry for bacteria) can be effectively treated in order to reduce the risk of relapse. The medical literature provides convincing evidence that antimicrobial prophylaxis can markedly reduce the frequency of relapse of erysipelas. Two recent studies performed by the ‘Prophylactic Antibiotics for the Treatment of Cellulitis at Home’ (PATCH) group have clearly confirmed the efficacy of antimicrobial prophylaxis. Penicillin remains the drug of choice. Treatment options in patients with penicillin allergy are limited by the rising prevalence of macrolide resistance among group A streptococci. Further research is required to clarify the optimal penicillin regimen as well as to develop new therapies for patients with allergy to penicillin.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
Thomas K, Crook A, Foster K, et al. Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the UK Dermatology Clinical Trials Network's PATCH II trial. Br J Dermatol. 2012;166(1):169–78. This was a randomized, double-blind, controlled trial evaluating the efficacy of prophylactic oral penicillin for prevention of recurrent cellulitis. In this trial, penicillin reduced the rate of recurrent celulitis but the result failed to achieve statistical significance.
Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med. 2013;368(18):1695–703. This was a randomized, double-blind, controlled trial evaluating the efficacy of prophylactic oral penicillin for prevention of recurrent cellulitis in patients with two or more episodes of cellulitis. In this trial, penicillin significantly reduced the rate of recurrence but the protective effect was lost several months after the end of prophylaxis.
Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373–406.
Elston DM. Epidemiology and prevention of skin and soft tissue infections. Cutis. 2004;73(5 Suppl):3–7.
Hirschmann JV. Antimicrobial prophylaxis in dermatology. Semin Cutan Med Surg. 2000;19(1):2–9.
Osmon DR. Antimicrobial prophylaxis in adults. Mayo Clin Proc. 2000;75(1):98–109.
Swartz MN, Pasternack MS. Cellulitis and sucutaneous tissue infections. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 6th ed. Philadelphia: Elsevier; 2005. p. 1172–94.
Hersh AL, Chambers HF, Maselli JH, Gonzales R. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med. 2008;168(14):1585–91.
Stulberg DL, Penrod MA, Blatny RA. Common bacterial skin infections. Am Fam Physician. 2002;66(1):119–24.
Madsen ST. Scarlet fever and erysipelas in Norway during the last hundred years. Infection. 1973;1(2):76–81.
Bartholomeeusen S, Vandenbroucke J, Truyers C, Buntinx F. Epidemiology and comorbidity of erysipelas in primary care. Dermatology. 2007;215(2):118–22.
Eriksson B, Jorup-Ronstrom C, Karkkonen K, et al. Erysipelas: clinical and bacteriologic spectrum and serological aspects. Clin Infect Dis. 1996;23(5):1091–8.
Pavlotsky F, Amrani S, Trau H. Recurrent erysipelas: risk factors. J Dtsch Dermatol Ges. 2004;2(2):89–95.
Jorup-Ronstrom C, Britton S. Recurrent erysipelas: predisposing factors and costs of prophylaxis. Infection. 1987;15(2):105–6.
Dupuy A, Benchikhi H, Roujeau JC, et al. Risk factors for erysipelas of the leg (cellulitis): case-control study. BMJ. 1999;318(7198):1591–4.
Stoberl C. The importance of local factors in recurrent erysipelas. Z Hautkr. 1985;60(9):712. 715–718, 721–713.
de Godoy JM, de Godoy MF, Valente A, et al. Lymphoscintigraphic evaluation in patients after erysipelas. Lymphology. 2000;33(4):177–80.
Smith RD, Spittell JA, Schirger A. Secondary lymphedema of the leg: its characteristics and diagnostic implications. JAMA. 1963;185:80–2.
Dreyer G, Noroes J, Figueredo-Silva J, Piessens WF. Pathogenesis of lymphatic disease in bancroftian filariasis: a clinical perspective. Parasitol Today. 2000;16(12):544–8.
Mallon E, Powell S, Mortimer P, Ryan TJ. Evidence for altered cell-mediated immunity in postmastectomy lymphoedema. Br J Dermatol. 1997;137(6):928–33.
Bjornsdottir S, Gottfredsson M, Thorisdottir AS, et al. Risk factors for acute cellulitis of the lower limb: a prospective case-control study. Clin Infect Dis. 2005;41(10):1416–22.
Roujeau JC, Sigurgeirsson B, Korting HC, et al. Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: a case-control study. Dermatology. 2004;209(4):301–7.
Mokni M, Dupuy A, Denguezli M, et al. Risk factors for erysipelas of the leg in Tunisia: a multicenter case-control study. Dermatology. 2006;212(2):108–12.
Cox NH. Oedema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg: a series with community follow-up. Br J Dermatol. 2006;155(5):947–50.
Dan M, Heller K, Shapira I, et al. Incidence of erysipelas following venectomy for coronary artery bypass surgery. Infection. 1987;15(2):107–8.
Baddour LM, Bisno AL. Recurrent cellulitis after saphenous venectomy for coronary bypass surgery. Ann Intern Med. 1982;97(4):493–6.
Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med. 1992;93(5):543–8.
Baddour LM. Breast cellulitis complicating breast conservation therapy. J Intern Med. 1999;245(1):5–9.
Bouma J, Dankert J. Recurrent acute leg cellulitis in patients after radical vulvectomy. Gynecol Oncol. 1988;29(1):50–7.
Dankert J, Bouma J. Recurrent acute leg cellulitis after hysterectomy with pelvic lymphadenectomy. Br J Obstet Gynaecol. 1987;94(8):788–90.
Lewis SD, Peter GS, Gomez-Marin O, Bisno AL. Risk factors for recurrent lower extremity cellulitis in a U.S. Veterans Medical Center population. Am J Med Sci. 2006;332(6):304–7.
McNamara DR, Tleyjeh IM, Berbari EF, et al. A predictive model of recurrent lower extremity cellulitis in a population-based cohort. Arch Intern Med. 2007;167(7):709–15.
Karppelin M, Siljander T, Vuopio-Varkila J, et al. Factors predisposing to acute and recurrent bacterial non-necrotizing cellulitis in hospitalized patients: a prospective case-control study. Clin Microbiol Infect. 2010;16(6):729–34.
Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666–74.
Stryjewski ME, Chambers HF. Skin and soft-tissue infections caused by community-acquired methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2008;46 Suppl 5:S368–77.
Forcade NA, Parchman ML, Jorgensen JH, et al. Prevalence, severity, and treatment of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infections in 10 medical clinics in Texas: a South Texas Ambulatory Research Network (STARNet) study. J Am Board Fam Med. 2011;24(5):543–50.
Oh CC, Ko HC, Lee HY, et al. Antibiotic prophylaxis for preventing recurrent cellulitis: A systematic review and meta-analysis. J Infect. 2014;69(1):26–34. This was a metaanalysis of five randomized, controlled trials evaluating antimicrobial prophylaxis for prevention of recurrent cellulitis. The results strongly sugest that such intervention is both safe and effective.
Chakroun M, Ben RF, Battikh R, et al. Benzathine penicillin prophylaxis in recurrent erysipelas. Med Mal Infect. 1994;24(10):894–7.
Kremer M, Zuckerman R, Avraham Z, Raz R. Long-term antimicrobial therapy in the prevention of recurrent soft-tissue infections. J Infect. 1991;22(1):37–40.
Sjoblom AC, Eriksson B, Jorup-Ronstrom C, et al. Antibiotic prophylaxis in recurrent erysipelas. Infection. 1993;21(6):390–3.
Hartel S, Gramatte T, Scholz A, Terhaag B. Long-term preventive use of sulfamerazine in chronic recurrent erysipelas. Dermatol Monatsschr. 1988;174(8):485–92.
Babb RR, Spittell Jr JA, Martin WJ, Schirger A. Prophylaxis of recurrent lymphangitis complicating lymphedema. JAMA. 1966;195(10):871–3.
Olszewski WL. Episodic dermatolymphangioadenitis (DLA) in patients with lymphedema of the lower extremities before and after administration of benzathine penicillin: a preliminary study. Lymphology. 1996;29(3):126–31.
Allard P, Stucker M, von Kobyletzki G, et al. Cyclical intravenous antibiosis as an effective therapy concept in chronic recurrent erysipelas. Hautarzt. 1999;50(1):34–8.
Duvanel T, Merot Y, Harms M, Saurat JH. Prophylactic antibiotics in erysipelas. Lancet. 1985;1(8442):1401.
Ziebart-Schroth A. Therapy and prophylaxis of recurrent erysipelas (author's transl). Med Klin. 1976;71:1197–9.
Bergkvist PI, Sjobeck K. Antibiotic and prednisolone therapy of erysipelas: a randomized, double blind, placebo-controlled study. Scand J Infect Dis. 1997;29(4):377–82.
Kasseroller R. Sodium selenite as prophylaxis against erysipelas in secondary lymphedema. Anticancer Res. 1998;18(3C):2227–30.
Leclerc S, Teixeira A, Mahe E, et al. Recurrent erysipelas: 47 cases. Dermatology. 2007;214(1):52–7.
Olszewski WL, Jamal S, Manokaran G, et al. The effectiveness of long-acting penicillin (penidur) in preventing recurrences of dermatolymphangioadenitis (DLA) and controlling skin, deep tissues, and lymph bacterial flora in patients with "filarial" lymphedema. Lymphology. 2005;38(2):66–80.
Vignes S, Dupuy A. Recurrence of lymphoedema-associated cellulitis (erysipelas) under prophylactic antibiotherapy: a retrospective cohort study. J Eur Acad Dermatol Venereol. 2006;20(7):818–22.
Koster JB, Kullberg BJ, van der Meer JW. Recurrent erysipelas despite antibiotic prophylaxis: an analysis from case studies. Neth J Med. 2007;65(3):89–94.
Sjoblom AC, Bruchfeld J, Eriksson B, et al. Skin concentrations of phenoxymethylpenicillin in patients with erysipelas. Infection. 1992;20(1):30–3.
Garcia LB, Benchetrit LC, Barrucand L. Penicillin post-antibiotic effects on the biology of group A streptococci. J Antimicrob Chemother. 1995;36(3):475–82.
Cherkasov VL. [Use of bicillin for the prevention of recurrent erysipelas]. Sov Med. 1975(11):85–9.
Wang JH, Liu YC, Cheng DL, et al. Role of benzathine penicillin G in prophylaxis for recurrent streptococcal cellulitis of the lower legs. Clin Infect Dis. 1997;25(3):685–9.
Stember RH. Prevalence of skin test reactivity in patients with convincing, vague, and unacceptable histories of penicillin allergy. Allergy Asthma Proc. 2005;26(1):59–64.
Solensky R. Hypersensitivity reactions to beta-lactam antibiotics. Clin Rev Allergy Immunol. 2003;24(3):201–20.
Solensky R. Drug desensitization. Immunol Allergy Clin North Am. 2004;24(3):425–43. vi.
Martin JM, Green M, Barbadora KA, Wald ER. Erythromycin-resistant group A streptococci in schoolchildren in Pittsburgh. N Engl J Med. 2002;346(16):1200–6.
Tamayo J, Perez-Trallero E, Gomez-Garces JL, Alos JI. Resistance to macrolides, clindamycin and telithromycin in Streptococcus pyogenes isolated in Spain during 2004. J Antimicrob Chemother. 2005;56(4):780–2.
Thomas C, Stevenson M, Riley TV. Antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea: a systematic review. J Antimicrob Chemother. 2003;51(6):1339–50.
Safdar N, Maki DG. The commonality of risk factors for nosocomial colonization and infection with antimicrobial-resistant Staphylococcus aureus, enterococcus, gram-negative bacilli, Clostridium difficile, and Candida. Ann Intern Med. 2002;136(11):834–44.
Kaplan EL, Johnson DR, Del Rosario MC, Horn DL. Susceptibility of group A beta-hemolytic streptococci to thirteen antibiotics: examination of 301 strains isolated in the United States between 1994 and 1997. Pediatr Infect Dis J. 1999;18(12):1069–72.
Shenoy RK, Kumaraswami V, Suma TK, et al. A double-blind, placebo-controlled study of the efficacy of oral penicillin, diethylcarbamazine or local treatment of the affected limb in preventing acute adenolymphangitis in lymphoedema caused by brugian filariasis. Ann Trop Med Parasitol. 1999;93(4):367–77.
Szuba A, Rockson SG. Lymphedema: classification, diagnosis and therapy. Vasc Med. 1998;3(2):145–56.
Didem K, Ufuk YS, Serdar S, Zumre A. The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery. Breast Cancer Res Treat. 2005;93(1):49–54.
Gloviczki P. Principles of surgical treatment of chronic lymphoedema. Int Angiol. 1999;18(1):42–6.
Kim DI, Huh SH, Hwang JH, Joh JH. Excisional surgery for chronic advanced lymphedema. Surg Today. 2004;34(2):134–7.
Olszewski WL. The treatment of lymphedema of the extremities with microsurgical lympho-venous anastomoses. Int Angiol. 1988;7(4):312–21.
Granzow JW, Soderberg JM, Kaji AH, Dauphine C. Review of current surgical treatments for lymphedema. Ann Surg Oncol. 2014;21(4):1195–201.
Young JR, Dewolfe VG. Recurrent lymphangitis of the leg associated with dermatophytosis. Report of 25 consecutive cases. Cleve Clin Q. 1960;27:19–24.
Haustein UF, Biella U, Tausch I, Knoll H. Treatment of chronic recurrent erysipelas with streptococcal vaccine. Hautarzt. 1989;40(4):215–21.
Massell BF, Honikman LH, Amezcua J. Rheumatic fever following streptococcal vaccination. Report of three cases. JAMA. 1969;207(6):1115–9.
Mason JM, Thomas KS, Crook AM, et al. Prophylactic antibiotics to prevent cellulitis of the leg: economic analysis of the PATCH I & II trials. PLoS One. 2014;9(2):e82694.
McArthur JD, Walker MJ. Domains of group A streptococcal M protein that confer resistance to phagocytosis, opsonization and protection: implications for vaccine development. Mol Microbiol. 2006;59(1):1–4.
Compliance with Ethics Guidelines
Conflict of Interest
Maciej Piotr Chlebicki and Choon Chiat Oh declare no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by the author.
Author information
Authors and Affiliations
Corresponding author
Additional information
This article is part of the Topical Collection on Skin, Soft Tissue, Bone and Joint Infectious Diseases
Rights and permissions
About this article
Cite this article
Chlebicki, M.P., Oh, C.C. Recurrent Cellulitis: Risk Factors, Etiology, Pathogenesis and Treatment. Curr Infect Dis Rep 16, 422 (2014). https://doi.org/10.1007/s11908-014-0422-0
Published:
DOI: https://doi.org/10.1007/s11908-014-0422-0