cellulitis


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Cellulitis

 

Definition

Cellulitis is a spreading bacterial infection just below the skin surface. It is most commonly caused by Streptococcus pyogenes or Staphylococcus aureus.

Description

The word "cellulitis" actually means "inflammation of the cells." Specifically, cellulitis refers to an infection of the tissue just below the skin surface. In humans, the skin and the tissues under the skin are the most common locations for microbial infection. Skin is the first defense against invading bacteria and other microbes. An infection can occur when this normally strong barrier is damaged due to surgery, injury, or a burn. Even something as small as a scratch or an insect bite allows bacteria to enter the skin, which may lead to an infection. Usually, the immune system kills any invading bacteria, but sometimes the bacteria are able to grow and cause an infection.
Once past the skin surface, the warmth, moisture, and nutrients allow bacteria to grow rapidly. Disease-causing bacteria release proteins called enzymes which cause tissue damage. The body's reaction to damage is inflammation which is characterized by pain, redness, heat, and swelling. This red, painful region grows bigger as the infection and resulting tissue damage spread. An untreated infection may spread to the lymphatic system (acute lymphangitis), the lymph nodes (lymphadenitis), the bloodstream (bacteremia), or into deeper tissues. Cellulitis most often occurs on the face, neck, and legs.

Orbital cellulitis

A very serious infection, called orbital cellulitis, occurs when bacteria enter and infect the tissues surrounding the eye. In 50-70% of all cases of orbital cellulitis, the infection spreads to the eye(s) from the sinuses or the upper respiratory tract (nose and throat). Twenty-five percent of orbital infections occur after surgery on the face. Other sources of orbital infection include a direct infection from an eye injury, from a dental or throat infection, and through the bloodstream.
Infection of the tissues surrounding the eye causes redness, swollen eyelids, severe pain, and causes the eye to bulge out. This serious infection can lead to a temporary loss of vision, blindness, brain abscesses, inflammation of the brain and spinal tissues (meningitis), and other complications. Before the discovery of antibiotics, orbital cellulitis caused blindness in 20% of patients and death in 17% of patients. Antibiotic treatment has significantly reduced the incidence of blindness and death.

Causes and symptoms

Although other kinds of bacteria can cause cellulitis, it is most often caused by Streptococcus pyogenes (the bacteria which causes strep throat) and Staphylococcus aureus. Streptococcus pyogenes is the so-called "flesh-eating bacteria" and, in rare cases, can cause a dangerous, deep skin infection called necrotizing fasciitis. Orbital cellulitis may be caused by bacteria which cannot grow in the presence of oxygen (anaerobic bacteria). In children, Haemophilus influenzae type B frequently causes orbital cellulitis following a sinus infection.
Streptococcus pyogenes can be picked up from a person who has strep throat or an infected sore. Other cellulitis-causing bacteria can be acquired from direct contact with infected sores. Persons who are at a higher risk for cellulitis are those who have a severe underlying disease (such as cancer, diabetes, and kidney disease), are taking steroid medications, have a reduced immune system (because of AIDS, organ transplant, etc.), have been burned, have insect bites, have reduced blood circulation to limbs, or have had a leg vein removed for coronary bypass surgery. In addition, chicken pox, human or animal bite wounds, skin wounds, and recent surgery can put a person at a higher risk for cellulitis.
The characteristic symptoms of cellulitis are redness, warmth, pain, and swelling. The infected area appears as a red patch that gets larger rapidly within the first 24 hours. A thick red line which progresses towards the heart may appear indicating an infection of the lymph vessels (lymphangitis). Other symptoms which may occur include fever, chills, tiredness, muscle aches, and a general ill feeling. Some people also experience nausea, vomiting, stiff joints, and hair loss at the infection site.
The characteristic symptoms of orbital cellulitis are eye pain, redness, swelling, warmth, and tenderness. The eye may bulge out and it may be difficult or impossible to move. Temporary loss of vision, pus drainage from the eye, chills, fever, headaches, vomiting, and a general ill feeling may occur.

Diagnosis

Cellulitis may be diagnosed and treated by a family doctor, an infectious disease specialist, a doctor who specializes in skin diseases (dermatologist), or in the case of orbital cellulitis, an eye doctor (ophthalmologist). The diagnosis of cellulitis is based mainly on the patient's symptoms. The patient's recent medical history is also used in the diagnosis.
Laboratory tests may be done to determine which kind of bacteria is causing the infection but these tests are not always successful. If the skin injury is visible, a sterile cotton swab is used to pick up a sample from the wound. If there is no obvious skin injury, a needle may be used to inject a small amount of sterile salt solution into the infected skin, and then the solution is withdrawn. The salt solution should pick up some of the bacteria causing the infection. A blood sample may be taken from the patient's arm to see if bacteria have entered the bloodstream. Also, a blood test may be done to count the number of white blood cells in the blood. High numbers of white blood cells suggest that the body is trying to fight a bacterial infection.
For orbital cellulitis, the doctor may often perform a special x-ray scan called computed tomography scan (CT). This scan enables the doctor to see the patient's head in cross-section to determine exactly where the infection is and see if any damage has occurred. A CT scan takes about 20 minutes.

Treatment

Antibiotic treatment is the only way to battle this potentially life-threatening infection. Mild to moderate cellulitis can be treated with the following antibiotics taken every four to eight hours by mouth:
  • penicillins (Bicillin, Wycillin, Pen Vee, V-Cillin)
  • erythromycin (E-Mycin, Ery-Tab)
  • cephalexin (Biocef, Keflex)
  • cloxacillin (Tegopen)
Other medications may be recommended, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) to relieve pain, and aspirin to decrease fever.
A normally healthy person is usually not hospitalized for mild or moderate cellulitis. General treatment measures include elevation of the infected area, rest, and application of warm, moist compresses to the infected area. The doctor will want to see the patient again to make sure that the antibiotic treatment is effective in stopping the infection.
Persons at high risk for severe cellulitis will probably be hospitalized for treatment and monitoring. Antibiotics may be given intravenously to patients with severe cellulitis. Complications such as deep infection, or bone or joint infections, might require surgical drainage and a longer course of antibiotic treatment. Extensive tissue destruction may require plastic surgery to repair. In cases of orbital cellulitis caused by a sinus infection, surgery may be required to drain the sinuses.

Prognosis

Over 90% of all cellulitis cases are cured after seven to ten days of antibiotic treatment. Persons with serious disease and/or those who are taking immunosuppressive drugs may experience a more severe form of cellulitis which can be life threatening. Serious complications include blood poisoning (bacteria growing in the blood stream), meningitis (brain and spinal cord infection), tissue death (necrosis), and/or lymphangitis (infection of the lymph vessels). Severe cellulitis caused by Streptococcus pyogenes can lead to destructive and life-threatening necrotizing fasciitis.

Key terms

Inflammation — A local, protective response to tissue injury. It is characterized by redness, warmth, swelling, and pain.
Necrotizing fasciitis — A destructive infection which follows severe cellulitis and involves the deep skin and underlying tissues.
Sinuses — Air cavities found in the bones of the head. The sinuses which are connected to the nose are prone to infection.

Prevention

Cellulitis may be prevented by wearing appropriate protective equipment during work and sports to avoid skin injury, cleaning cuts and skin injuries with antiseptic soap, keeping wounds clean and protected, watching wounds for signs of infection, taking the entire prescribed dose of antibiotic, and maintaining good general health. Persons with diabetes should try to maintain good blood sugar control.

Resources

Periodicals

Lewis, Ronald T. "Soft Tissue Infections." World Journal of Surgery 22, no. 2 (February 1998): 146-51.

cellulitis

 [sel″u-li´tis]
a diffuse inflammatory process within solid tissues, characterized by edema, redness, pain, and interference with function; it may be caused by infection with streptococci, staphylococci, or other organisms. It usually occurs in the loose tissues beneath the skin, but may also occur in tissues beneath mucous membranes or around muscle bundles or surrounding organs.

Erysipelas, a surface cellulitis of the skin, is characterized by patches of skin that are red, have sharply defined borders, and feel hot to the touch. Other types of skin cellulitis are also characterized by hot red patches, but the borders are less clearly defined. Red streaks extending from the patch indicate that lymph vessels have been infected.

Facial cellulitis is a type involving the face, especially the cheek or periorbital or orbital tissues, although other regions such as the neck may be affected. ludwig's angina is a cellulitis of the tissues of the floor of the mouth and neck, in the area around the submaxillary gland. Orbital cellulitis is an acute inflammation of the eye socket.
Orbital cellulitis. From McQuillan et al., 2002.
Pelvic cellulitis involves the tissues surrounding the uterus and is better known as parametritis.

Cellulitis is potentially dangerous but usually can be treated successfully with antimicrobials. Any cellulitis on the face must be given special attention because the infection may extend directly to the cavernous sinuses of the brain.
eosinophilic cellulitis wells syndrome.

cel·lu·li·tis

(sel'yū-lī'tis),
Inflammation of subcutaneous, loose connective tissue (formerly called cellular tissue).

cellulitis

(sĕl′yə-lī′tĭs)
n.
An acute, spreading, bacterial infection of the skin and subcutaneous tissues. Cellulitis often originates from an infected wound and can lead to serious illness in the elderly or those with compromised immune systems.

cellulitis

Dermatology An acute, diffuse and boggy, suppurative inflammation of deep subcutaneous tissues and sometimes muscle Etiology Infection of wounds 2º to surgery, trauma, burns or other skin lesions–eg, erysipelas, by bacteria, especially group A streptococci and Staphylococcus aureus; it also occurs in immunocompromised Pts Clinical Edema, warmth, tenderness, indistinct margins, tendency to spread along tissue planes Risk factors Insect bites/stings, animal/human bites, skin wounds, peripheral vascular disease, DM, ischemic ulcers; recent heart, chest, dental surgery, use of steroids, immunosuppressants Management Antibiotics. See St Helenian cellulitis, Synergistic necrotizing cellulitis. Cf Erysipelas.

cel·lu·li·tis

(sel'yū-lī'tis)
Inflammation of subcutaneous, loose connective tissue (formerly called cellular tissue).

cellulitis

(sel?yu-lit'is ) [ cellula + -itis, ]
Enlarge picture
CELLULITIS
A spreading bacterial infection of the skin and subcutaneous tissues, usually caused by streptococcal or staphylococcal infections in adults (and occasionally by Haemophilus species in children). It may occur following damage to skin from an insect bite, an excoriation, or other wound. The extremities, esp. the lower legs, are the most common sites. Adjacent soft tissue may be involved. Affected skin becomes inflamed: red, swollen, warm to the touch, and tender. Spread of infection up lymphatic channels may occur. Cellulitis involving the face is called erysipelas. When it affects the lower extremities, cellulitis must be differentiated from stasis dermatitis, which is associated most commonly with bilateral, chronic dependent edema and, occasionally, with deep venous thrombosis. Risk factors for cellulitis include diabetes mellitus, lymphedema, venous stasis or insufficiency, immune suppression, injection drug use, malnutrition, peripheral vascular disease, and previous skin diseases. See: illustration; necrotizing fasciitis

Etiology

Bacteria gain access through breaks in the skin and spread rapidly, overwhelming normal body defenses; lesions between the toes from athlete's foot are common entry sites.

Treatment

For mild cases of cellulitis, oral antibiotics may be effective depending on the causative organism. For severe cases, intravenous penicillinase-resistant penicillins are used; surgical débridement to obtain cultures and to rule out fasciitis is recommended for patients with diabetes.

CAUTION!

Rarely, group A streptococcal cellulitis may be complicated by exfoliative dermatitis or infection of the subcutaneous fat and fascia, causing necrosis (necrotizing fasciitis), a condition popularly ascribed to the action of “flesh-eating bacteria.”

Patient care

Blood cultures should be obtained from patients with cellulitis to assess for sepsis before beginning therapy with antibiotics. The affected body part should be elevated above the level of the heart. Outlining the affected area with a skin marker allows the caregiver to readily determine if inflamed tissues are responding to therapy. Size, shape, color, and temperature of the affected area and surrounding tissues should be documented and any drainage described. Applying warm soaks to the area increases vasodilation, thus decreasing edema and relieving pain. Pain should be treated with prescribed oral analgesics and anti-inflammatory drugs. Blood sugars, if elevated, should be lowered to normal levels (preferably about 126 mg/dl or less). Patients on prolonged bedrest should be given heparin to prevent deep venous thrombosis as well as stool softeners to prevent constipation. Patients who develop cellulitis are often at risk for recurrence; they should learn general skin hygiene, how to clean cuts, scratches, cracked skin, and abrasions, and the importance of prompt treatment for infections.

dissecting cellulitis of the scalp

An inflammatory pustular disease of the scalp, similar to acne conglobata or hidradenitis suppurativa. It can be treated surgically, with isotretinoin, or with laser therapy. Synonym: perifolliculitis capitis abscedens

eosinophilic cellulitis

A rash marked by firm, swollen, itchy patches that appear suddenly. The patches may be oval or circular, violet or red, and are associated with abnormally high blood eosinophil levels. The cause is unknown.
Synonym: Wells syndrome

orbital cellulitis

Postseptal cellulitis.

pelvic cellulitis

Parametritis.

periorbital cellulitis

Preseptal cellulitis.

postseptal cellulitis

Facial infection invading the orbit. Synonym: orbital cellulitis

preseptal cellulitis

Soft tissue infection limited to the tissues anterior to the orbital septum. Synonym: periorbital cellulitis
illustrationillustration

cellulitis

Spreading inflammation of tissue, most commonly the skin, caused by infection with organisms, often streptococci, which secrete enzymes that break down natural defensive planes in the tissue and allow spread of infection. Cellulitis usually responds well to antibiotics.

cel·lu·li·tis

(sel'yū-lī'tis)
Inflammation of subcutaneous, loose connective tissue.

Patient discussion about cellulitis

Q. What is Cellulitis? I am a bit overweight and have cellulite, does this mean I have Cellulitis?

A. Cellulite is a dimpled appearance to your skin. It is harmless. Whereas, Cellulitis is a common, potentially serious bacterial skin infection. Cellulitis appears as a swollen, red area of skin that feels hot and tender, and it may spread rapidly. Skin on lower legs is most commonly affected, though cellulitis can occur anywhere on your body or face. Cellulitis canalso affect tissues underlying the skin and can spread to the lymph nodes and bloodstream. If it is left untreated, it can spread and become life-threatening.

Q. How to treat cellulitis? My Mother is 73 and has been diagnosed with cellulitis on her leg. She is in a lot of pain. What is the most effective treatment for it?

A. Here is a movie with tips on managing cellulitis:
http://www.youtube.com/watch?v=w1_3NzwgsgY

Q. Is Diabetes a risk factor for developing cellulitis? I am 50 years old and have type 2 diabetes. Is it true that diabetes can cause cellulitis? if so, what can be done to prevent it?

A. To help prevent cellulitis and other infections, follow these measures anytime you have a skin wound:
Wash your wound daily with soap and water.
Apply an antibiotic cream or ointment. Cover your wound with a bandage. Change bandages often. Change them at least daily or whenever the bandage becomes wet or dirty.
Watch for signs of infection. Redness, pain and drainage all signal possible infection and the need for medical evaluation.
People with diabetes and those with poor circulation need to take extra precautions to prevent skin wounds and treat any cuts or cracks in the skin promptly. Good skin-care measures include the following:
Moisturize your skin regularly.
Trim your fingernails and toenails carefully.
Protect your hands and feet. Promptly treat any superficial skin infections, such as athlete's foot.

More discussions about cellulitis
References in periodicals archive ?
Which of the following is most important to do for this patient to help prevent future episodes of cellulitis?
Thirty-eight patients with orbital or preseptal cellulitis who had been admitted to the Ankara Training and Research Hospital, Department of Paediatrics between September 2015 and February 2017 were retrospectively studied.
During the 6-year period, the initial medical database search identified 816 patients who were admitted to the hospital with the diagnosis of cellulitis. Three-hundred and fifty two subjects whose blood cultures were not obtained, 245 patients without cellulitis on admission, six cases who were discharged from the emergency department, and eight patients with osteomyelitis were all excluded.
Forty-eight patients (38.4%) were diagnosed with cellulitis, 47 (37.6%) with an abscess, and 30 (24.0%) with an abscess complicated by surrounding cellulitis.
Retrospective chart review was performed on cases with culture-positive Klebsiella pneumoniae orbital cellulitis. A total of thirteen cases were identified between May 1995 and March 2017 for detailed review.
Preseptal cellulitis was found in 32 (88.9%) of 36 patients who were hospitalized and treated with a diagnosis of orbital tissue infection between January 2014 and December 2015, and orbital cellulitis was found in four (11.9%).
The odds of cellulitis admissions increased by roughly 3.55% for each 5[degrees] F increment in temperature.
We report the case of severe contact dermatitis in an 87-year-old female that was misdiagnosed and treated for cellulitis of the lower leg.
His symptoms were suspected to be due to cellulitis, and he was subsequently admitted to our hospital for the treatment of the cellulitis.
Because of our initial impression of left neck lymphadenitis with facial cellulitis, the patient was administered parenteral amoxicillin and clavulanic acid.
Shortly after injuring her hand, she'd sought care at an outpatient facility, where she was given a diagnosis of cellulitis and a prescription for an oral antibiotic.
Local examination for cellulitis, bleeding, and fang mark was done meticulously.