1. Erysipelas

2. Definition
Erysipelas is a superficial bacterial
skin infection that is characteristically
extends into cutaneous lymphatics .
It was referred to as :
Saint Anthony's Fire (= ergotism or
erysipelas or Herpes zoster )

3. Pathophysiology
•Bacterial
inoculation into an
area of skin trauma
is the initial event in
developing
erysipelas.

4. Pathophysiology
The source of the bacteria
in facial erysipelas is often
the host's naso-
pharynx, and a history of
recent streptococcal
pharyngitis has been
reported in up to one third
of cases.

5. Pathophysiology
Lymphoscintigraphy in patients
with a first-time episode of
lower extremity erysipelas has
documented lymphatic
impairment in both affected
and non affected legs.

6. regional lymph node
swelling and
tenderness

7. Causative organism
* Streptococci are the primary
cause of erysipelas.
* Most facial infections are
attributed to group A
streptococci,
*lower extremity infections
being caused by non–group A
streptococci.

8. causes
•Streptococcal toxins are thought to
contribute to the brisk inflammation
that is pathognomonic of this infection.
*No clear proof has emerged that other
bacteria cause typical erysipelas,
although they clearly coexist with
streptococci at sites of inoculation.

9. causes
Recently, atypical forms reported to be
caused by :
* Streptococcus pneumoniae,
*Klebsiella pneumoniae,
* Haemophilus influenzae,
*Yersinia enterocolitica,
*Moraxella species,
they should be considered in cases refractory
to standard antibiotic therapy.

10. Race
Erysipelas infections affect persons of all
races.
Sex
•Erysipelas is common in females.
• at an earlier age it is more in males ( more
activities).
• However predisposing factors, rather than
gender, account for any male/female
differences in incidence.

11. Age
All age groups are susiptable.
The peak incidence at 60-80 years
old, especially in patients :
= At high-risk .
= immuno-compromised .
= those with lymphatic drainage
problems (eg, after mastectomy, pelvic
surgery, bypass grafting).

12. Clinical

13. symptoms
Prodromal symptoms :
malaise.
chills.
high fever.
often begin before the onset of the skin
lesions and usually are present within 48
hours of cutaneous involvement..

14. symptoms
Pruritus .
burning .
tenderness.
are typical complaints

15. Physical

16. Erysipelas begins
as a small
erythematous
patch that
progresses to a
fiery-
red, indurated
, tense, and shiny
plaque.

17. The lesion classically
exhibits raised
sharply demarcated
advancing margins.
Local signs of
inflammation
warmth,
edema,
tenderness
are universal.

18. Lymphatic
involvement often
is manifested by
overlying skin
streaking and
regional
lymphadenopathy

19. More severe
infections may
exhibit numerous
vesicles and bullae
along with
petechiae and
even frank
necrosis.

20. Erysipelas
of
the face

21. Erysipelas
Of
the leg

22. Erysipelas
the
buttock

23. Erysipelas
of
the ear Pena

24. Differential Diagnoses

25. Differential Diagnoses
1) Erythema Annulare Centri-
fugum
2) Stasis Dermatitis
3) Cellulitis
4) Erysipeloid

26. Erythema Annulare Centrifugum
* Eruptions occur at any
age.
* begins as small raised
pink-red spot that slowly
enlarges and forms a ring
shape while the central
area flattens and clears.
There may be an inner
rim of scale.

27. Erythema Annulare Centrifugum
Lesions most often
appear on the
thighs, legs, face, trunk
and arms.
linked to underlying
diseases , viral
, bacterial or even
tumor.

28. Stasis
Dermatitis

29. cellulitis

30. Erysipeloid
* acute bacterial infection of traumatized skin.
* caused by Erysipelothrix rhusiopathiae
(gram positive rod-shaped bacterium), which
cause animal and human infections.
* Direct contact between infected meat and
traumatized human skin results in Erysipeloid.
•more common among
farmers, butchers, cooks, homemakers.
* Lesions most commonly affect the hands.

31. Erysipeloid
* Lesions consist of
well-
demarcated, bright
red-to-purple plaques
with a smooth, shiny
surface.
•Lesions are warm
and tender.

32. Laboratory Studies

33. Laboratory Studies
* In classic erysipelas, no
laboratory workup is required
for diagnosis or treatment.
* Cultures are best reserved for
immunocopromized patient in
whom an atypical etiologic agent
is suspected.

34. Imaging Studies
Imaging studies are not usually
indicated and are of low yield.
MRI and bone scintigraphy are
helpful when early osteoarticular
involvement is suspected.
In this setting, standard
radiographic findings typically are
normal.

35. Histological Findings
The histological hallmarks of erysipelas are
*marked dermal edema,
*vascular dilatation,
*streptococcal invasion of lymphatics & tissues.
This bacterial invasion results in a dermal
inflammatory infiltrate consisting of
neutrophils and mononuclear cells.
The epidermis is often secondarily involved.
Rarely, bacterial invasion of local blood vessels
may be seen.

36. Treatment

37. Hospitalization for close monitoring
and IV. antibiotics is recommended
for :
1) severe cases.
2) infants.
3) elderly patients.
4) patients who are immune-
compromised.

38. Medical Care
* Elevation and rest of the affected
limb are recommended to reduce
local swelling, inflammation, and pain.
* Saline wet dressings should be
applied to ulcerated and necrotic
lesions and changed every 2-12 hours,
depending on the severity of the
infection.

39. Medical Care
* penicillin has remained first-line therapy.
administered orally or IM. for 10-20 days.
Dosing : Adult
Penicillin G procaine: 0.6-1.2 million U IM bid for 10 d
Penicillin VK: 250-500 mg PO qid for 10-14 d
Pediatric : Penicillin G procaine: <30 kg: 300,000 U/d
>30 kg: Administer as in adults
Penicillin VK:
<12 years: 25-50 mg/kg/d PO divided tid/qid;
not to exceed 3 g/d
>12 years: Administer as in adults

40. Medical Care
*A first-generation cephalosporin or
macrolide, such as erythromycin or
azithromycin, may be used if the patient has
an allergy to penicillin.
Dosing
Adult
250-500 mg PO qid for 10 d
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO divided
q6-8h; double dose for severe infection.

41. •Two new drugs:
• roxithromycin & pristinamycin,
have been reported to be extremely
effective in the treatment of erysipelas.
* Several studies have demonstrated greater
efficacy and fewer adverse effects with
these drugs compared with penicillin.
*Currently, FDA has not approved these
drugs in the United States, but they are in
use in Europe.

42. Recurrent
erysipelas

43. Recurrent erysipelas
Patients with recurrent erysipelas
should be educated regarding :
•local antisepstic .
•general wound care.
•Predisposing lower extremity skin
lesions (eg , tineapedis , toe
web intertrigo , stasis ulcers) should
be treated aggressively to prevent
super-infection.

44. Recurrent erysipelas
•Long-term prophylactic antibiotic therapy
generally is accepted, but no true guidelines are
available.
•Treatment regimens should be tailored to the
patient.
•One reported regimen is benzathine
penicillin G at 2.4 MU IM. every 3 weeks
for up to 2 years . Two-week intervals
have also been used.

45. Surgical Care
Debridement is necessary
only in severe infections
with necrosis or gangrene.

46. Complications

47. Complications
1) The most common
complications of erysipelas are :
* abscess,
* gangrene,
* Thrombophlebitis .

48. Complications
2) Less common complications
(<1%) are :
*acute glomerulonephritis ,
*endocarditis ,
*septicemia,
*streptococcal toxic shock
syndrome.

49. Prognosis
* The prognosis for patients
with erysipelas is excellent.
* local recurrence has been
reported in up to 20% of
patients with predisposing
conditions