Cellulitis
Questionnaire/history:
Acutely red, painful, hot, swollen, tender skin with rapid spreading?
Fever?
Malaise?
Location?Bilateral (rare)?
Past medical history?
Current medication?
Known drug allergies?
Examination:
Acutely red, painful, hot, swollen, tender skin with rapid spreading?
Leg raise test (raise the leg to 45 degrees for 1-2 minutes - redness persists in cellulitis and usually disappears with other causes)?
Investigation:
Swab: only if broken skin and risk of uncommon organisms (eg water exposure, bites, facial cellulitis)?
Differential diagnosis:
DVT (?risk factors, often less erythema), thrombophlebitis, gout, ruptured Baker’s cyst, necrotising fasciitis, lipodermatosclerosis (with acute painful inflammation above the ankles responding to potent topical steroids), lymphedema, venous insufficiency)?
Management:
Assessed and treated for risk factors and co-morbidities (eg diabetes, alcohol misuse)?
Urgently admission
If symptoms or signs of more serious illness (eg severely unwell (eg tachycardia, vomiting, confusion), unstable comorbidities (eg uncontrolled diabetes), vascular compromise (eg severe PAD), necrotising fasciitis, orbital cellulitis, sepsis etc.)?
(Note: CKS suggested that patients with cellulitis who have a comorbidity (Eron Class II) eg diabetes, obesity, PAD or chronic venous insufficiency should have IV antibiotics)
Referral
If severely unwell, lymphangitis, infection near nose/eyes, risk of uncommon pathogen, spreading infection not responding to oral antibiotics, cannot take oral antibiotics?
Management in primary care
If no systemic symptoms and uncontrolled co-morbidities:
Antibiotic treatment for 5-7 days (up to 14 days in limited cases):
Flucloxacillin 500mg qds first line, 1g QDS (off-label) if impaired circulation, clarithromycin, erythromycin or doxycycline if penicillin allergy (dosage information)
Co-amoxiclav for mild facial cellulitis managed in the community
If river or seawater exposure discussed with microbiology?
Advised:
Elevate limb
Analgesia if required
May be an ↑ in redness over first 24-48 hrs (?toxin release)
Review in 2-3 days if no better
Resource(s):