Wednesday, January 09, 2019

Erysipelas in a 69 yo Woman

presented by Henry Foong
Ipoh, Malaysia

A 69-yr-old woman was seen with a 2-day history of rapidly enlarged swelling on the right cheek.  Initially she felt some discomfort on the right ear and then involved the right cheek.  She had no fever.
There was no history of trauma.  She had a history of hypertension. 

Examination showed unilateral swelling on the right cheek with increased temperature, tenderness and redness extending from right forehead to the right lower jaw.  It appeared oedematous, with swelling of the ipsilateral upper eyelid. It had a well defined raised border. The rash did not cross the bridge of the nose to the opposite cheek. No blisters were seen. Her regional nodes were not enlarged.

Clinically she has erysipelas.

TWBC 12,900 (N84%)
blood sugar  8.5 mol/l
BU and serum electrolytes normal
LFT normal

Erysipelas affects the superficial layer of the skin while cellulitis affects the deeper part of the dermis. There were no clusters of vesicles or erosions to suggest herpes zoster. She was not keen to be admitted and preferred oral medication as an outpatient  She was treated with oral cefuroxime 500mg bd for 10 days with wet compress dressing on the affected face. The erysipelas cleared with the treatment.


  1. Erysipelas is a superficial infection of the epidermis most frequently caused by Group A Streptococcus pyogenes. It is difficult to culture because it is pauci-bacillary. In spite of this, it produces a robust inflammatory reaction which can induce a post-streptococcal arthritis, glomerulonephritis, and rarely acute rheumatic fever. Clinical signs of of this infection include a raised indurated border, lymphangitic spread, a peau d'orange appearance to the overlying skin, and worsening of the erythema during the first 24 hours of antibiotic therapy. It is easily treated with penicillin VK as there is no resistance that has yet appeared despite 75 years of its use. There are intriguing trials using antiinflammatory agents (prednisone and ibuprofen) to hasten the resolution of the swelling. This observation suggests that combination therapy of an antiinflammatory drug with an antibiotic could hasten resolution of symptoms. When erysipelas causes infection of the lower limbs, consider compression dressings over the affected skin to hasten resolution of swelling.

  2. from Henry Foong: "I see erysipelas affecting the lower limbs much more common than those involving the face. There have been instances when the patient do not respond to penicillin V. Also, in my personal view, oral prednisolone is not advisable as an inflammatory agent in these patients as it may cause immunosuppression and makes the infection more invasive and more mortality."


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