Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Cellulitis and erysipelas

Larry M Baddour, MD, FIDSA
Section Editors
Daniel J Sexton, MD
Sheldon L Kaplan, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Cellulitis and erysipelas are skin infections that develop as a result of bacterial entry via breaches in the skin barrier [1]. Cellulitis and erysipelas manifest as areas of skin erythema, edema, and warmth. They differ in that erysipelas involves the upper dermis and superficial lymphatics, whereas cellulitis involves the deeper dermis and subcutaneous fat.

The clinical manifestations, diagnosis, microbiology, and treatment of cellulitis and erysipelas will be reviewed here. Issues related to special forms of cellulitis are discussed separately. (See "Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities" and "Initial management of animal and human bites" and "Soft tissue infections due to dog and cat bites" and "Soft tissue infections following water exposure" and "Orbital cellulitis".)


The incidence is about 200 cases per 100,000 patient-years [2]. Cellulitis is observed most frequently among middle-aged individuals and older adults, while erysipelas occurs in young children and older adults [3,4].

Predisposing factors include disruption to the skin barrier as a result of trauma (such as insect bites, abrasions, penetrating wounds, or injection drug use), inflammation (such as eczema or radiation therapy), preexisting skin infection (such as impetigo or tinea pedis), varicella, and edema (due to venous insufficiency) [5,6]. Lymphatic obstruction following surgical procedures also predisposes to cellulitis. Such procedures include saphenous venectomy, breast cancer axillary node dissection, and lymph node dissection for pelvic malignancy [7-11]. Breaks in the skin between the toes ("toe web intertrigo") are perhaps the most important potential sites for pathogen entry [5,12]. However, breaches in the skin may be small and clinically inapparent. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Post-venectomy cellulitis' and "Cellulitis following pelvic lymph node dissection".)


The vast majority of cases of erysipelas are caused by beta-hemolytic streptococci [4,13-15].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Dec 2016. | This topic last updated: Thu Jan 12 00:00:00 GMT+00:00 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA 2016; 316:325.
  2. McNamara DR, Tleyjeh IM, Berbari EF, et al. Incidence of lower-extremity cellulitis: a population-based study in Olmsted county, Minnesota. Mayo Clin Proc 2007; 82:817.
  3. Ellis Simonsen SM, van Orman ER, Hatch BE, et al. Cellulitis incidence in a defined population. Epidemiol Infect 2006; 134:293.
  4. Eriksson B, Jorup-Rönström C, Karkkonen K, et al. Erysipelas: clinical and bacteriologic spectrum and serological aspects. Clin Infect Dis 1996; 23:1091.
  5. Dupuy A, Benchikhi H, Roujeau JC, et al. Risk factors for erysipelas of the leg (cellulitis): case-control study. BMJ 1999; 318:1591.
  6. 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; 167:709.
  7. Dan M, Heller K, Shapira I, et al. Incidence of erysipelas following venectomy for coronary artery bypass surgery. Infection 1987; 15:107.
  8. Baddour LM, Bisno AL. Recurrent cellulitis after saphenous venectomy for coronary bypass surgery. Ann Intern Med 1982; 97:493.
  9. Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med 1992; 93:543.
  10. Baddour LM. Breast cellulitis complicating breast conservation therapy. J Intern Med 1999; 245:5.
  11. Dankert J, Bouma J. Recurrent acute leg cellulitis after hysterectomy with pelvic lymphadenectomy. Br J Obstet Gynaecol 1987; 94:788.
  12. Semel JD, Goldin H. Association of athlete's foot with cellulitis of the lower extremities: diagnostic value of bacterial cultures of ipsilateral interdigital space samples. Clin Infect Dis 1996; 23:1162.
  13. Bernard P, Toty L, Mounier M, et al. Early detection of streptococcal group antigens in skin samples by latex particle agglutination. Arch Dermatol 1987; 123:468.
  14. Bernard P, Bedane C, Mounier M, et al. Streptococcal cause of erysipelas and cellulitis in adults. A microbiologic study using a direct immunofluorescence technique. Arch Dermatol 1989; 125:779.
  15. Chartier C, Grosshans E. Erysipelas. Int J Dermatol 1990; 29:459.
  16. Leppard BJ, Seal DV, Colman G, Hallas G. The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. Br J Dermatol 1985; 112:559.
  17. Peralta G, Padrón E, Roiz MP, et al. Risk factors for bacteremia in patients with limb cellulitis. Eur J Clin Microbiol Infect Dis 2006; 25:619.
  18. Björnsdóttir S, Gottfredsson M, Thórisdóttir AS, et al. Risk factors for acute cellulitis of the lower limb: a prospective case-control study. Clin Infect Dis 2005; 41:1416.
  19. Carratalà J, Rosón B, Fernández-Sabé N, et al. Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis. Eur J Clin Microbiol Infect Dis 2003; 22:151.
  20. Siljander T, Karppelin M, Vähäkuopus S, et al. Acute bacterial, nonnecrotizing cellulitis in Finland: microbiological findings. Clin Infect Dis 2008; 46:855.
  21. Jeng A, Beheshti M, Li J, Nathan R. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore) 2010; 89:217.
  22. Swartz MN. Clinical practice. Cellulitis. N Engl J Med 2004; 350:904.
  23. Parada JP, Maslow JN. Clinical syndromes associated with adult pneumococcal cellulitis. Scand J Infect Dis 2000; 32:133.
  24. Porras MC, Martínez VC, Ruiz IM, et al. Acute cellulitis: an unusual manifestation of meningococcal disease. Scand J Infect Dis 2001; 33:56.
  25. Patel M, Ahrens JC, Moyer DV, DiNubile MJ. Pneumococcal soft-tissue infections: a problem deserving more recognition. Clin Infect Dis 1994; 19:149.
  26. Capdevila O, Grau I, Vadillo M, et al. Bacteremic pneumococcal cellulitis compared with bacteremic cellulitis caused by Staphylococcus aureus and Streptococcus pyogenes. Eur J Clin Microbiol Infect Dis 2003; 22:337.
  27. Page KR, Karakousis PC, Maslow JN. Postoperative pneumococcal cellulitis in systemic lupus erythematosus. Scand J Infect Dis 2003; 35:141.
  28. Givner LB, Mason EO Jr, Barson WJ, et al. Pneumococcal facial cellulitis in children. Pediatrics 2000; 106:E61.
  29. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med 1996; 334:240.
  30. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
  31. Stevens DL, Bisno AL, Chambers HF, 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 2014; 59:147.
  32. Chartier C, Grosshans E. Erysipelas: an update. Int J Dermatol 1996; 35:779.
  33. Barzilai A, Choen HA. Isolation of group A streptococci from children with perianal cellulitis and from their siblings. Pediatr Infect Dis J 1998; 17:358.
  34. Thorsteinsdottir B, Tleyjeh IM, Baddour LM. Abdominal wall cellulitis in the morbidly obese. Scand J Infect Dis 2005; 37:605.
  35. Bruun T, Oppegaard O, Hufthammer KO, et al. Early Response in Cellulitis: A Prospective Study of Dynamics and Predictors. Clin Infect Dis 2016; 63:1034.
  36. Perl B, Gottehrer NP, Raveh D, et al. Cost-effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis 1999; 29:1483.
  37. Kielhofner MA, Brown B, Dall L. Influence of underlying disease process on the utility of cellulitis needle aspirates. Arch Intern Med 1988; 148:2451.
  38. Hook EW 3rd, Hooton TM, Horton CA, et al. Microbiologic evaluation of cutaneous cellulitis in adults. Arch Intern Med 1986; 146:295.
  39. Sachs MK. The optimum use of needle aspiration in the bacteriologic diagnosis of cellulitis in adults. Arch Intern Med 1990; 150:1907.
  40. Sigurdsson AF, Gudmundsson S. The etiology of bacterial cellulitis as determined by fine-needle aspiration. Scand J Infect Dis 1989; 21:537.
  41. Newell PM, Norden CW. Value of needle aspiration in bacteriologic diagnosis of cellulitis in adults. J Clin Microbiol 1988; 26:401.
  42. Lebre C, Girard-Pipau F, Roujeau JC, et al. Value of fine-needle aspiration in infectious cellulitis. Arch Dermatol 1996; 132:842.
  43. Duvanel T, Auckenthaler R, Rohner P, et al. Quantitative cultures of biopsy specimens from cutaneous cellulitis. Arch Intern Med 1989; 149:293.
  44. Crisp JG, Takhar SS, Moran GJ, et al. Inability of polymerase chain reaction, pyrosequencing, and culture of infected and uninfected site skin biopsy specimens to identify the cause of cellulitis. Clin Infect Dis 2015; 61:1679.
  45. Hook EW 3rd, Hooton TM, Horton CA, et al. Microbiologic evaluation of cutaneous cellulitis in adults. Arch Intern Med 1986; 146:295.
  46. Woo PC, Lum PN, Wong SS, et al. Cellulitis complicating lymphoedema. Eur J Clin Microbiol Infect Dis 2000; 19:294.
  47. Hilmarsdóttir I, Valsdóttir F. Molecular typing of Beta-hemolytic streptococci from two patients with lower-limb cellulitis: identical isolates from toe web and blood specimens. J Clin Microbiol 2007; 45:3131.
  48. Barbic D, Chenkin J, Cho DD, et al. In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. BMJ Open 2017; 7:e013688.
  49. Tayal VS, Hasan N, Norton HJ, Tomaszewski CA. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med 2006; 13:384.
  50. Alsaawi A, Alrajhi K, Alshehri A, et al. Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: a systematic review of the literature. Eur J Emerg Med 2015.
  51. Beltran J. MR imaging of soft-tissue infection. Magn Reson Imaging Clin N Am 1995; 3:743.
  52. Stamenkovic I, Lew PD. Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. N Engl J Med 1984; 310:1689.
  53. Schmid MR, Kossmann T, Duewell S. Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol 1998; 170:615.
  54. Halilovic J, Heintz BH, Brown J. Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess. J Infect 2012; 65:128.
  55. Hepburn MJ, Dooley DP, Skidmore PJ, et al. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med 2004; 164:1669.
  56. Bruun T, Oppegaard O, Kittang BR, et al. Etiology of Cellulitis and Clinical Prediction of Streptococcal Disease: A Prospective Study. Open Forum Infect Dis 2016; 3:ofv181.
  57. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 2006; 355:666.
  58. Miller LG, Daum RS, Creech CB, et al. Clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated skin infections. N Engl J Med 2015; 372:1093.
  59. Pallin DJ, Binder WD, Allen MB, et al. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis 2013; 56:1754.
  60. Bernard P, Plantin P, Roger H, et al. Roxithromycin versus penicillin in the treatment of erysipelas in adults: a comparative study. Br J Dermatol 1992; 127:155.
  61. Martin JM, Green M, Barbadora KA, Wald ER. Erythromycin-resistant group A streptococci in schoolchildren in Pittsburgh. N Engl J Med 2002; 346:1200.
  62. Treatment of community-associated MRSA infections. Med Lett Drugs Ther 2006; 48:13.
  63. Facinelli B, Spinaci C, Magi G, et al. Association between erythromycin resistance and ability to enter human respiratory cells in group A streptococci. Lancet 2001; 358:30.
  64. Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med 2013; 368:1695.
  65. van Zuuren EJ, Fedorowicz Z, Alper B, Mitsuma SF. Penicillin to prevent recurrent leg cellulitis: a critical appraisal. Br J Dermatol 2014; 171:1300.
  66. Klempner MS, Styrt B. Prevention of recurrent staphylococcal skin infections with low-dose oral clindamycin therapy. JAMA 1988; 260:2682.
  67. Jorup-Rönström C, Britton S. Recurrent erysipelas: predisposing factors and costs of prophylaxis. Infection 1987; 15:105.
  68. Oh CC, Ko HC, Lee HY, et al. Antibiotic prophylaxis for preventing recurrent cellulitis: a systematic review and meta-analysis. J Infect 2014; 69:26.
  69. 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:e82694.