Cellulitis / Erysipelas in Pediatric and Primary Lymphedema

Cellulitis, which is also known as erysipelas, is a common problem for people with lymphedema. It’s thought to be caused mainly by beta-hemolytic streptococci. It’s common in people with primary lymphedema and secondary lymphedema and can occur in adults and children. Cellulitis is a bacterial infection affecting the skin and the subcutaneous tissues. Recurrent episodes can occur in people with lymphedema. The clinical features include flu-like symptoms and fever, often of rapid onset. There is pain, redness, rash, increased swelling, warmth, tenderness, and possible blistering/skin breakdown in the area of lymphedema. The pattern varies from person to person. It may be triggered by wounds or athlete’s foot but sometimes there is no obvious trauma. This picture shows a classical appearance of cellulitis in the patient with lymphedema of the leg. The diagnosis of cellulitis is a clinical one based on the features I’ve just described. There are no specific tests that demonstrate cellulitis but white blood count (WBC), C-reactive protein (CRP), and microbiology, including blood cultures, may be helpful. To confirm the diagnosis, it’s important to exclude skin conditions such as eczema and lipodermatosclerosis. The treatment is with antibiotics. The type of antibiotic varies depending upon recommendations by individual countries and localities. For example, oral amoxicillin or flucloxacillin can be used. If the condition is severe, or there is sepsis, then intravenous antibiotics are necessary. The duration of the course of antibiotics is 10 to 14 days at least. We usually recommend that patients remove compression temporarily if the limb is painful and replace it as soon as possible, or as soon as it is tolerated, and particularly when they start to mobilise again. Recurrent cellulitis is a significant problem. Acute episodes are unpleasant and may require hospital admission, particularly if there is a sepsis. There can be loss of time from work. Each episode damages lymph vessels making the lymphedema worse. Points to consider in recurrent cellulitis and whether to use antibiotic prophylaxis: the main issue is to confirm that it is really cellulitis that we’re seeing. Any skin conditions such as eczema should be managed and it’s important to use emollients to improve the care of the skin and for moisturization. Reducing the limb volume and treating the lymphedema with decongestive lymphatic therapy (DLT) or surgery or other treatments is important as this reduces the chance of recurrence of cellulitis. When is antibiotic prophylaxis thought to be appropriate? We usually recommend this if there have been two or more episodes of cellulitis in a year. Antibiotics which can be used for this are oral phenoxymethylpenicillin but in some countries intramuscular benzathine penicillin is preferred. We also suggest that it is considered whether a course of antibiotics, that patients keep at home to use promptly if they develop an episode of cellulitis, be considered. The websites where the consensus documents from the UK can be found are shown on this slide.

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