Description

• Distinct form of cellulitis: an acute, well-demarcated, superficial bacterial skin infection (most commonly on face or leg) with lymphatic involvement almost always caused by Streptococcus pyogenes
• Usually acute, but a chronic recurrent form can also exist
• Nonpurulent
• System(s) affected: skin, exocrine

Epidemiology

• Predominant age: infants, children, and adults >45 years
• Greatest in elderly (>75 years)
• No gender/racial predilection

Incidence

• Erysipelas occurs in ~1/1,000 persons/year.
• Incidence on the rise since the 1980s (1)

Prevalence
Unknown

Etiology and Pathophysiology

• Group A streptococci induce inflammation and activation of the contact system, a proinflammatory pathway with antithrombotic activity, releasing proteinases and proinflammatory cytokines.
• The generation of antibacterial peptides and the release of bradykinin, a proinflammatory peptide, increase vascular permeability and induce fever and pain.
• The M proteins from the group A streptococcal cell wall interact with neutrophils, leading to the secretion of heparin-binding protein, an inflammatory mediator that also induces vascular leakage.
• This cascade of reactions leads to the symptoms seen in erysipelas: fever, pain, erythema, and edema.
• Group A β-hemolytic streptococci primarily; commonly S. pyogenes, occasionally, other Streptococcus groups C/G
• Rarely, group B streptococci/Staphylococcus aureus may be involved.

Risk Factors

• Disruption in the skin barrier (surgical incisions, insect bites, eczematous lesions, local trauma, abrasions, dermatophytic infections, intravenous drug user [IVDU])
• Chronic diseases (diabetes, malnutrition, nephrotic syndrome, heart failure)
• Immunocompromised (HIV)/debilitated
• Fissured skin (especially at the nose and ears)
• Toe-web intertrigo and lymphedema
• Leg ulcers/stasis dermatitis
• Venous/lymphatic insufficiency (saphenectomy, varicose veins of leg, phlebitis, radiotherapy, mastectomy, lymphadenectomy)
• Alcohol abuse
• Morbid obesity
• Recent streptococcal pharyngitis
• Varicella

General Prevention

• Good skin hygiene
• It is recommended that predisposing medical conditions, such as tinea pedis and stasis dermatitis, be appropriately managed first.
• Men who shave within 5 days of facial erysipelas are more likely to have a recurrence.
• With recurrences, search for other possible sources of streptococcal infection (e.g., tonsils, sinuses).
• Compression stockings should be encouraged for patients with lower extremity edema.
• Consider suppressive prophylactic antibiotic therapy, such as penicillin, in patients with >2 episodes in a 12-month period.

Pediatric Considerations
Group B Streptococcus may be a cause of erysipelas in neonates/infants.