Cellulitis and other skin conditions

Cellulitis

Usually unilateral, demarcated erythema, swelling, tenderness and warmthTx.: long term tx. of cellulitis has not been well studied, but in a small group of patients with recurrent cellulitis, the tx. group (Erythromycin 250 mg bid) didn’t develop cellulitis compared to 8 in the non-tx. group.

- There are no published studies to identify who is a candidate for long term tx. and for how long but uptodate suggest the following if considering long-term tx. for cellulitis

cont.

-ABX should be at least for 12 months, (Acute tx. should be for 12-14 days)-Macrolides aren’t recommended d/t increased resistance, instead use Dicloxacillin 500 mg po bid. will cover both beta-hemolytic streptococci and S. Aureas-If MRSA is suspected, use Clindamycin 150 mg po q day (think of C. diff education)- Tx. Tinea pedis: Naftifine gel and terbinafine cream are allylamine-class products that are appropriate treatment options for topical therapy

Think of pseudocellulitis

Stasis dermatitis is the most common cause of pseudocellulitis

Chronic venous insufficiency: occurs when the venous pressure is increased and the return of blood is impaired (mm. pump dysfunction),

Unabated venous hypertension may result in dermal changes with hyperpigmentation, subcutaneous tissue fibrosis (“lipodermatosclerosis”), and eventual ulceration. (Chronic venous insufficiency)

capillary leak, fibrin deposition, erythrocyte and leukocyte sequestration, thrombocytosis, and inflammation. These processes impair oxygenation of the skin and subcutaneous tissues. The clinical manifestations of severe venous hypertension and tissue hypoxia are edema, hyperpigmentation, subcutaneous fibrosis, and ulcer formation

Chronic venous insufficiency

BLE swelling and redness is rare for dx. of cellulitis and more indicative of stasis dermatitis

Lymphedema and leg ulcerations can be underlying cause of symptoms and acute or repeated cellulitis

Management of stasis dermatitis● General measures to reduce edema and venous hypertension (eg, leg

elevation, daily walking, exercise, weight reduction)● Continuous compression therapy● Systemic therapy, including venoactive or phlebotonic drugs (eg,

hydroxyethylrutoside, escin [horse chestnut extract], calcium dobesilate), flavonoids (eg, diosmin and hesperidin, diosmiplex), or pentoxifyllin

● Surgical therapy

Acute stasis dermatitis

Tx: We suggest topical corticosteroids for patients with stasis dermatitis who have erythema, pruritus, vesiculation, and oozing. High- or mid-potency corticosteroids

ie. Triamcinolone 0.1% cream, apply once or twice daily for 1-2 weeks

Compression

Tx: closed dressings that are also compression, unna boots (1x/wk. change)4-layer compression wrapOTC hosiery (last 6 months if wearing everyday)TED hose (last 6 months if wearing everyday)

Compression therapy is contraindicated in patients with peripheral artery disease, cellulitis, and acute deep vein thrombosis. Noninvasive arterial studies should be performed on patients with lower extremity ulcer who have weak or nonpalpable pulses or risk factors for atherosclerosis. Cellulitis and deep vein thrombosis should be treated prior to placement of compression bandages

Obtaining ultrasound

Patients with persistent symptoms (pain, aching, swelling) and signs (telangiectasias, reticular veins, varicose veins, skin changes, ulceration) of venous disease after a period of conservative management, typically three months, and documented reflux (ie, retrograde flow >0.5 second duration) as a source of their symptoms are candidates for vein ablation therapy

If a clinical diagnosis of venous insufficiency or obstruction cannot be established but symptoms are strongly suggestive.

In patients with signs of chronic venous disease but whose symptoms are questionably related to the venous disease.

In atypical cases, such as an unusually early age of onset (<40 years) of symptoms, or following trauma.

In cases of ulceration. Patients with ulceration due to superficial venous reflux may benefit from venous ablation

procedures. Significantly decreased ulcer recurrence rates have been found with removal or ablation of greater or small

saphenous veins [3].

In patients with clinically suspected venous disease who do not respond to standard conservative measures

When to refer

Arterial insufficiency, non-healing ulcers, persistent stasis dermatitis, dx. uncertainty