ERYSIPELAS AS AN ACUTE STREPTOCOCCAL SKIN INFECTION: A LITERATURE REVIEW
DOI:
https://doi.org/10.31435/ijitss.3(51).2026.6504Keywords:
Erysipelas, Cellulitis, Streptococcus pyogenes, Lymphedema, Antibiotic Prophylaxis, Social ServicesAbstract
Erysipelas is an acute bacterial infection of the upper dermis and superficial lymphatic vessels. Beta hemolytic streptococci cause most typical cases. The disease often starts suddenly with painful erythema, warmth, swelling, fever, chills, and a raised or sharply demarcated skin border. Most patients respond to antibiotic therapy, but recurrent episodes can damage lymphatic drainage and create chronic edema. This narrative review summarizes current evidence on etiology, risk factors, clinical variants, diagnosis, treatment, complications, prevention, and care organization. It gives special attention to recurrent lower limb disease, because recurrence links infection with mobility loss, work absence, repeated antibiotic exposure, compression therapy, community nursing, and social support. The review also distinguishes infectious erysipelas from carcinoma erysipeloides, a malignant mimic that can delay cancer diagnosis when clinicians treat persistent erythema as infection.
References
Al Ameer, A., Al Nemer, A., Alharbi, A., Sait, K., Alsaif, F., & Alkaff, T. (2015). Carcinoma erysipeloides as a presenting feature of breast carcinoma: A case report and brief review of literature. Case Reports in Oncology, 8(3), 396–401. https://doi.org/10.1159/000441338
Bisno, A. L., & Stevens, D. L. (1996). Streptococcal infections of skin and soft tissues. The New England Journal of Medicine, 334(4), 240–245. https://doi.org/10.1056/NEJM199601253340407
Bjornsdottir, S., Gottfredsson, M., Thorisdottir, A. S., Gunnarsson, G. B., Rikardsdottir, H., Kristjansson, M., & Hilmarsdottir, I. (2005). Risk factors for acute cellulitis of the lower limb: A prospective case control study. Clinical Infectious Diseases, 41(10), 1416–1422. https://doi.org/10.1086/497127
Brishkoska-Boshkovski, V., Kondova-Topuzovska, I., Damevska, K., Petrov, A., & Dimovski, A. (2019). Comorbidities as risk factors for acute and recurrent erysipelas. Open Access Macedonian Journal of Medical Sciences, 7(6), 937–942. https://doi.org/10.3889/oamjms.2019.214
Burian, E. A., Karlsmark, T., Franks, P. J., Keeley, V., Moffatt, C. J., & Quéré, I. (2024). Factors associated with cellulitis in lymphoedema of the arm: An international cross sectional study. BMC Infectious Diseases, 24, 103. https://doi.org/10.1186/s12879–023–08839-z
Cannon, J., Dyer, J., Carapetis, J., & Manning, L. (2018). Epidemiology and risk factors for recurrent severe lower limb cellulitis: A longitudinal cohort study. Clinical Microbiology and Infection, 24(10), 1084–1088. https://doi.org/10.1016/j.cmi.2018.01.018
Carlesimo, M., Rossi, A., La Pietra, M., Cacchi, C., Feliziani, G., Mari, E., & Narcisi, A. (2009). Erysipelas like carcinoma of the breast: A case report and review of the literature. Dermatology Online Journal, 15(3), 12.
Cox, N. H. (2006). Oedema as a risk factor for multiple episodes of cellulitis or erysipelas of the lower leg: A series with community follow up. British Journal of Dermatology, 155(5), 947–950. https://doi.org/10.1111/j.1365–2133.2006.07419.x
Dalal, A., Eskin-Schwartz, M., Mimouni, D., Ray, S., Days, W., Hodak, E., Leibovici, L., & Paul, M. (2017). Interventions for the prevention of recurrent erysipelas and cellulitis. Cochrane Database of Systematic Reviews, 2017(6), CD009758. https://doi.org/10.1002/14651858.CD009758.pub2
D Dupuy, A., Benchikhi, H., Roujeau, J. C., Bernard, P., Vaillant, L., Chosidow, O., Sassolas, B., Guillaume, J. C., Grob, J. J., & Bastuji-Garin, S. (1999). Risk factors for erysipelas of the leg (cellulitis): Case-control study. BMJ, 318(7198), 1591–1594. https://doi.org/10.1136/bmj.318.7198.1591
Halpern, J., Holder, R., & Langford, N. J. (2008). Ethnicity and other risk factors for acute lower limb cellulitis: A UK based prospective case control study. British Journal of Dermatology, 158(6), 1288–1292. https://doi.org/10.1111/j.1365–2133.2008.08489.x
Inghammar, M., Rasmussen, M., & Linder, A. (2014). Recurrent erysipelas: Risk factors and clinical presentation. BMC Infectious Diseases, 14, 270. https://doi.org/10.1186/1471–2334–14–270
Karppelin, M., Siljander, T., Vuopio-Varkila, J., Kere, J., Huhtala, H., Vuento, R., & Syrjänen, J. (2010). Factors predisposing to acute and recurrent bacterial non necrotizing cellulitis in hospitalized patients: A prospective case control study. Clinical Microbiology and Infection, 16(6), 729–734. https://doi.org/10.1111/j.1469–0691.2009.02906.x
Ki, V., & Rotstein, C. (2008). Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Canadian Journal of Infectious Diseases and Medical Microbiology, 19(2), 173–184. https://doi.org/10.1155/2008/846453
Ko, D. S. C., Lerner, R., Klose, G., & Cosimi, A. B. (1998). Effective treatment of lymphedema of the extremities. Archives of Surgery, 133(4), 452–458. https://doi.org/10.1001/archsurg.133.4.452
Krasagakis, K., Samonis, G., Maniatakis, P., Georgala, S., & Tosca, A. D. (2006). Bullous erysipelas: Clinical presentation, staphylococcal involvement and methicillin resistance. Dermatology, 212(1), 31–35. https://doi.org/10.1159/000089019
Lazzarini, L., Conti, E., Tositti, G., & de Lalla, F. (2005). Erysipelas and cellulitis: Clinical and microbiological spectrum in an italian tertiary care hospital. Journal of Infection, 51(5), 383–389. https://doi.org/10.1016/j.jinf.2004.12.010
Li, D. G., Xia, F. D., Khosravi, H., Dewan, A. K., Pallin, D. J., Baugh, C. W., & Kupper, T. S. (2018). Outcomes of early dermatology consultation for inpatients diagnosed with cellulitis. JAMA Dermatology, 154(5), 537–543. https://doi.org/10.1001/jamadermatol.2017.6197
Mistry, R. D. (2013). Skin and soft tissue infections. Pediatric Clinics of North America, 60(5), 1063–1082. https://doi.org/10.1016/j.pcl.2013.06.011
Morris, A. D. (2008). Cellulitis and erysipelas. Clinical Evidence, 2008, 1708.
Nava, G., Greer, K., Patterson, J., & Lin, K. Y. (2009). Metastatic cutaneous breast carcinoma: A case report and review of the literature. Canadian Journal of Plastic Surgery, 17(1), 25–27. https://doi.org/10.1177/229255030901700105
Oh, C. C., Ko, H. C., Lee, H. Y., Safdar, N., Maki, D. G., & Chlebicki, M. P. (2014). Antibiotic prophylaxis for preventing recurrent cellulitis: A systematic review and meta analysis. Journal of Infection, 69(1), 26–34. https://doi.org/10.1016/j.jinf.2014.02.011
Ong, B. S., Dotel, R., & Tran, S. (2022). Recurrent cellulitis: Who is at risk and how effective is antibiotic prophylaxis? International Journal of General Medicine, 15, 6561-6572. https://doi.org/10.2147/IJGM.S355955
Phoenix, G., Das, S., & Joshi, M. (2012). Diagnosis and management of cellulitis. BMJ, 345, e4955. https://doi.org/10.1136/bmj.e4955
Quirke, M., Ayoub, F., McCabe, A., Boland, F., Smith, B., O'Sullivan, R., & Wakai, A. (2017). Risk factors for nonpurulent leg cellulitis: A systematic review and meta-analysis. British Journal of Dermatology, 177(2), 382–394. https://doi.org/10.1111/bjd.15186
Raff, A. B., & Kroshinsky, D. (2016). Cellulitis: A review. JAMA, 316(3), 325–337. https://doi.org/10.1001/jama.2016.8825
Roujeau, J. C., Sigurgeirsson, B., Korting, H. C., Kerl, H., & Paul, C. (2004). Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: A case control study. Dermatology, 209(4), 301–307. https://doi.org/10.1159/000080853
Sapuła, M., Krankowska, D., Wiercińska-Drapało, A., & Kuchar, E. (2020). In search of risk factors for recurrent erysipelas and cellulitis of the lower limb: A cross sectional study of epidemiological characteristics of patients hospitalized due to skin and soft tissue infections. Interdisciplinary Perspectives on Infectious Diseases, 2020, 1307232. https://doi.org/10.1155/2020/1307232
Shien, T., Shimizu, C., Akashi-Tanaka, S., Hojo, T., & Kinoshita, T. (2014). Clinicopathological features of erysipeloid carcinoma of the breast. Breast Cancer, 21(3), 297–302. https://doi.org/10.1007/s12282–012–0382–4
Stevens, D. L., Bisno, A. L., Chambers, H. F., Dellinger, E. P., Goldstein, E. J. C., Gorbach, S. L., Hirschmann, J. V., Kaplan, S. L., Montoya, J. G., & Wade, J. C. (2014). Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clinical Infectious Diseases, 59(2), e10-e52. https://doi.org/10.1093/cid/ciu296
Sullivan, T., & de Barra, E. (2018). Diagnosis and management of cellulitis. Clinical Medicine, 18(2), 160–163. https://doi.org/10.7861/clinmedicine.18–2–160
Sundheimer, C., & Henghold, W. B. (2019). Erysipelas carcinomatosum. Dermatology Online Journal, 25(1)
Thomas, K. S., Crook, A. M., Foster, K. A., Mason, J. M., Chalmers, J. R., Nasr, I. S., Brindle, R. J., Nunn, A. J., Williams, H. C., & U.K. Dermatology Clinical Trials Network PATCH Trial Team. (2012). Prophylactic antibiotics for the prevention of cellulitis of the leg: Results of the UK dermatology clinical trials network patch ii trial. British Journal of Dermatology, 166(1), 169–178. https://doi.org/10.1111/j.1365–2133.2011.10586.x
Thomas, K. S., Crook, A. M., Nunn, A. J., Foster, K. A., Mason, J. M., Chalmers, J. R., Nasr, I. S., Brindle, R. J., English, J., Meredith, S. K., Reynolds, N. J., de Berker, D., Mortimer, P. S., Williams, H. C., & U.K. Dermatology Clinical Trials Network PATCH I Trial Team. (2013). Penicillin to prevent recurrent leg cellulitis. The New England Journal of Medicine, 368(18), 1695–1703. https://doi.org/10.1056/NEJMoa1206300
Vignes, S., Poizeau, F., Dupuy, A., & Arrault, M. (2022). Cellulitis risk factors for patients with primary or secondary lymphedema. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 10(1), 179–185. https://doi.org/10.1016/j.jvsv.2021.06.011
Walsh, T. L., Chan, L., Konopka, C. I., Burkitt, M., Moffa, M. A., Bremmer, D. N., Murillo, M. A., Watson, R., Chan-Tompkins, N. H., & Nagel, J. L. (2016). Appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients. BMC Infectious Diseases, 16, 721. https://doi.org/10.1186/s12879–016–2067–0
Warren, A. G., Brorson, H., Borud, L. J., & Slavin, S. A. (2007). Lymphedema: A comprehensive review. Annals of Plastic Surgery, 59(4), 464–472.
Webb, E., Neeman, T., Bowden, F. J., Gaida, J., & Mumford, V. (2020). Compression therapy to prevent recurrent cellulitis of the leg. The New England Journal of Medicine, 383(7), 630–639. https://doi.org/10.1056/NEJMoa1917197
Webb, E., Neeman, T., Bowden, F. J., Mumford, V., & Bissett, B. (2023). Compression therapy is cost saving in the prevention of lower limb recurrent cellulitis in patients with chronic edema. Lymphatic Research and Biology, 21(3), 260–267. https://doi.org/10.1089/lrb.2022.0029
Weng, Q. Y., Raff, A. B., Cohen, J. M., Gunasekera, N., Okhovat, J. P., Vedak, P., Joyce, C., Kroshinsky, D., & Mostaghimi, A. (2017). Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatology, 153(2), 141–146. https://doi.org/10.1001/jamadermatol.2016.3816
Yadav, K., Suh, K. N., Eagles, D., & Perry, J. J. (2015). Predictors of oral antibiotic treatment failure for nonpurulent skin and soft tissue infections in the emergency department. Academic Emergency Medicine, 22(2), 163–170. https://doi.org/10.1111/acem.12584
Zervos, M. J., Freeman, K., Vo, L., Haque, N., Pokharna, H., Raut, M., & Kim, M. (2012). Epidemiology and outcomes of complicated skin and soft tissue infections in hospitalized patients. Journal of Clinical Microbiology, 50(2), 238–245. https://doi.org/10.1128/JCM.05817–11
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Copyright (c) 2026 Grzegorz Kasparek, Krzysztof Maksym Kasparek, Julia Obersztyn, Jakub Maksymilian Bajer, Hubert Kulawinek, Adrianna Szczecińska, Wiktoria Glanert, Aleksandra Mliczek , Piotr Mrozek, Marta Czech

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