Skip to main content

Advertisement

SpringerLink
Log in

Cellulitis and Its Mimickers: an Approach to Diagnosis and Management

  • Hospital-Based Dermatology (L Guggina and C Nguyen, Section Editors)
  • Published:
Current Dermatology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This article reviews the pathophysiology, clinical presentation, clinical mimickers, and management strategies for cellulitis in hospitalized patients.

Recent Findings

Cellulitis is a common skin infection with increasing hospitalizations and healthcare costs. The clinical presentation of cellulitis is mimicked by a wide spectrum of diagnoses including other infectious, inflammatory, vascular, and neoplastic conditions. Evaluating for and optimizing modifiable risk factors is paramount to treating cellulitis and preventing recurrences. These include local factors such as edema, previous cellulitis, skin barrier disruption due to trauma or pre-existing infection, skin inflammation, obesity, and immunosuppression.

Summary

Cellulitis is an infection of the deep dermis and subcutaneous tissue presenting with expanding erythema, edema, and warmth. Misdiagnosis is common and adds a significant burden to healthcare costs. A thorough history and physical examination can help distinguish cellulitis from its clinical mimickers. In addition to antimicrobial therapy, predisposing dermatological conditions should be addressed to prevent recurrences.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Weng QY, Raff AB, Cohen JM, Gunasekera N, Okhovat JP, Vedak P, et al. Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatol. 2017;153(2):141–6.

    Article  Google Scholar 

  2. Peterson RA, Polgreen LA, Cavanaugh JE, Polgreen PM. Increasing incidence, cost, and seasonality in patients hospitalized for cellulitis. Open Forum Infect Dis. 2017;4(1):ofx008.

  3. Garcia BM, Cruz-Diaz C, Agnihothri R, Shinkai K. Distinguishing cellulitis from its noninfectious mimics: approach to the red leg. Infect Dis Clin North Am. 2021;35(1):61–79.

    Article  Google Scholar 

  4. Rrapi R, Chand S, Kroshinsky D. Cellulitis: a review of pathogenesis, diagnosis, and management. Med Clin North Am. 2021;105(4):723–35.

    Article  Google Scholar 

  5. Raff AB, Kroshinsky D. Cellulitis: a review. JAMA. 2016;316(3):325–37.

    Article  Google Scholar 

  6. Bystritsky RJ. Cellulitis. Infect Dis Clin North Am. 2021;35(1):49–60.

    Article  Google Scholar 

  7. Bystritsky R, Chambers H. Cellulitis and soft tissue infections. Ann Intern Med. 2018;168(3):ITC17–32.

  8. • Lopez M, Roberson ML, Strassle PD, Ogunleye A. Epidemiology of lymphedema-related admissions in the United States: 2012–2017. Surg Oncol. 2020;35:249–253. A retrospective analysis of lymphedema-related hospitalizations from 2012 to 2017 described the epidemiology of hospitalizations due to lymphedema in the United States and suggested that although the mortality is low, the prevalence of disease continues to increase as does the burden to the healthcare system; their data demonstrated that 92% of lymphedema cases were associated with cellulitis. Counseling older lymphedema patients with comorbidities on early symptoms and signs of infection and prompt treatment of same may reduce mortality.

  9. Quirke M, Ayoub F, McCabe A, Boland F, Smith B, O’Sullivan R, et al. Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol. 2017;177(2):382–94.

    Article  CAS  Google Scholar 

  10. Chand S, Rrapi R, Gabel CK, Song S, Shah R, El Saleeby C, et al. Clinical features and outcomes for nonabscess cellulitis in hospitalized pediatric patients. J Am Acad Dermatol. 2022;86(1):226–9.

    Article  Google Scholar 

  11. Long B, Gottlieb M. Diagnosis and management of cellulitis and abscess in the emergency department setting: an evidence-based review. J Emerg Med. 2022;62(1):16–27.

    Article  Google Scholar 

  12. Jothishankar B, Stein SL. Impact of skin color and ethnicity. Clin Dermatol. 2019;37(5):418–29.

    Article  Google Scholar 

  13. Ko LN, Raff AB, Garza-Mayers AC, Dobry AS, Ortega-Martinez A, Anderson RR, et al. Skin surface temperatures measured by thermal imaging aid in the diagnosis of cellulitis. J Invest Dermatol. 2018;138(3):520–6.

    Article  CAS  Google Scholar 

  14. Hirschmann JV, Raugi GJ. Lower limb cellulitis and its mimics: Part I. Lower limb cellulitis. J Am Acad Dermatol. 2012;67(2):163.e1–163.e12.

  15. Cranendonk DR, Lavrijsen APM, Prins JM, Wiersinga WJ. Cellulitis: current insights into pathophysiology and clinical management. Neth J Med. 2017;75(9):13.

    Google Scholar 

  16. • Brindle RJ, Ijaz A, Davies P. Procalcitonin and cellulitis: correlation of procalcitonin blood levels with measurements of severity and outcome in patients with limb cellulitis. Biomark Biochem Indic Expo Response Susceptibility Chem. 2019;24(2):127–130. The authors demonstrated that procalcitonin levels are generally low in limb cellulitis and cannot be used to confirm the diagnosis or the need for antibiotic therapy. Procalcitonin is a poor predictor of early improvement.

  17. Bailey E, Kroshinsky D. Cellulitis: diagnosis and management. Dermatol Ther. 2011;24(2):229–39.

    Article  Google Scholar 

  18. Chira S, Miller LG. Staphylococcus aureus is the most common identified cause of cellulitis: a systematic review. Epidemiol Infect. 2010;138(3):313–7.

    Article  CAS  Google Scholar 

  19. Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64(2):148–55.

    Article  Google Scholar 

  20. Ko LN, Garza-Mayers AC, St John J, Strazzula L, Vedak P, Dobry AS, et al. Clinical usefulness of imaging and blood cultures in cellulitis evaluation. JAMA Intern Med. 2018;178(7):994–6.

    Article  Google Scholar 

  21. Raff AB, Weng QY, Cohen JM, Gunasekera N, Okhovat JP, Vedak P, et al. A predictive model for diagnosis of lower extremity cellulitis: a cross-sectional study. J Am Acad Dermatol. 2017;76(4):618-625.e2.

    Article  Google Scholar 

  22. Ezaldein HH, Waldman A, Grunseich K, Jubanyik K. Risk stratification for cellulitis versus noncellulitic conditions of the lower extremity: a retrospective review of the NEW HAvUN criteria. Cutis. 2018;102(1):E8-12.

    PubMed  Google Scholar 

  23. Ljungström L, Pernestig AK, Jacobsson G, Andersson R, Usener B, Tilevik D. Diagnostic accuracy of procalcitonin, neutrophil-lymphocyte count ratio, C-reactive protein, and lactate in patients with suspected bacterial sepsis. PLoS ONE. 2017;12(7): e0181704.

    Article  Google Scholar 

  24. David CV, Chira S, Eells SJ, Ladrigan M, Papier A, Miller LG, Craft N. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011 Mar 15;17(3):1. PMID: 21426867.

  25. • Edwards G, Freeman K, Llewelyn MJ, Hayward G. What diagnostic strategies can help differentiate cellulitis from other causes of red legs in primary care? BMJ. 2020;368:m54. This review noted that although novel approaches such as thermal imaging, clinical prediction models, point-of-care tests, and a visually based computerized diagnostic decision support system could potentially aid the diagnosis of cellulitis, there is very limited and weak evidence to support their use in primary care.

  26. Ross Russell AL, Dryden MS, Pinto AA, Lovett JK. Lyme disease: diagnosis and management. Pract Neurol. 2018;18(6):455–64.

    Article  Google Scholar 

  27. Rebman AW, Yang T, Mihm EA, Novak CB, Yoon I, Powell D, et al. The presenting characteristics of erythema migrans vary by age, sex, duration, and body location. Infection. 2021;49(4):685–92.

    Article  CAS  Google Scholar 

  28. Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med. 2017;377(23):2253–65.

    Article  Google Scholar 

  29. Fernando SM, Tran A, Cheng W, Rochwerg B, Kyeremanteng K, Seely AJE, et al. Necrotizing soft tissue infection: diagnostic accuracy of physical examination, imaging, and LRINEC score: a systematic review and meta-analysis. Ann Surg. 2019;269(1):58–65.

    Article  Google Scholar 

  30. Clark SC, Zirwas MJ. Management of occupational dermatitis. Dermatol Clin. 2009;27(3):365–83, vii–viii.

  31. Dalbeth N, Gosling AL, Gaffo A, Abhishek A. Gout. Lancet Lond Engl. 2021;397(10287):1843–55.

  32. Cohen PR. Sweet’s syndrome–a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet J Rare Dis. 2007;26(2):34.

    Article  Google Scholar 

  33. Na HD, Yan H, Park CH. Misdiagnosis of pyoderma gangrenosum increases medical costs and prolongs hospital stay: a case report. Int J Low Extrem Wounds. 2021;23:15347346211011870.

    Google Scholar 

  34. Sundaresan S, Migden MR, Silapunt S. Stasis dermatitis: pathophysiology, evaluation, and management. Am J Clin Dermatol. 2017;18(3):383–90.

    Article  Google Scholar 

  35. Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003;349(13):1227–35.

    Article  CAS  Google Scholar 

  36. Lee DH, Park AY, Seo BK, Kim YS, Lee KY, Cha SH. Primary neuroendocrine carcinoma of the breast with clinical features of inflammatory breast carcinoma: a case report and literature review. J Breast Cancer. 2015;18(4):404–8.

    Article  Google Scholar 

  37. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJC, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis Off Publ Infect Dis Soc Am. 2014;59(2):e10-52.

    Article  Google Scholar 

  38. O’Riordan W, Green S, Overcash JS, Puljiz I, Metallidis S, Gardovskis J, et al. Omadacycline for acute bacterial skin and skin-structure infections. N Engl J Med. 2019;380(6):528–38.

    Article  Google Scholar 

  39. Brown BD, Hood Watson KL. Cellulitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 May 14]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK549770/

  40. Ko LN, Garza-Mayers AC, St John J, Strazzula L, Vedak P, Shah R, et al. Effect of dermatology consultation on outcomes for patients with presumed cellulitis: a randomized clinical trial. JAMA Dermatol. 2018;154(5):529–36.

    Article  Google Scholar 

  41. Arakaki RY, Strazzula L, Woo E, Kroshinsky D. The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial. JAMA Dermatol. 2014;150(10):1056–61.

    Article  Google Scholar 

  42. Strazzula L, Cotliar J, Fox LP, Hughey L, Shinkai K, Gee SN, et al. Inpatient dermatology consultation aids diagnosis of cellulitis among hospitalized patients: a multi-institutional analysis. J Am Acad Dermatol. 2015;73(1):70–5.

    Article  Google Scholar 

  43. Jain SR, Hosseini-Moghaddam SM, Dwek P, Gupta K, Elsayed S, Thompson GW, et al. Infectious diseases specialist management improves outcomes for outpatients diagnosed with cellulitis in the emergency department: a double cohort study. Diagn Microbiol Infect Dis. 2017;87(4):371–5.

    Article  Google Scholar 

Download references

Author information

Author notes

  1. Bianca Biglione and Bethany Cucka are co-first authors and contributed equally to this manuscript.

Authors and Affiliations

  1. Department of Dermatology, Massachusetts General Hospital, 50 Staniford Street, 2nd Floor, Boston, MA, 02114, USA

    Bianca Biglione, Bethany Cucka & Daniela Kroshinsky

Authors
  1. Bianca Biglione
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bethany Cucka
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Daniela Kroshinsky
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Daniela Kroshinsky.

Ethics declarations

Conflict of Interest

None.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Topical Collection on Hospital-Based Dermatology

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Biglione, B., Cucka, B. & Kroshinsky, D. Cellulitis and Its Mimickers: an Approach to Diagnosis and Management. Curr Derm Rep 11, 138–145 (2022). https://doi.org/10.1007/s13671-022-00363-8

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13671-022-00363-8

Keywords

Search

Navigation