Cellulitis in patients with lymphoedema (Guidelines)

Signs and symptoms may be mild or severe, including one or more:

• Redness: either diffuse cellulitis , demarcated area (erysipelas) or in streaks along the limb (lymphangitis)
• Heat
• Increased swelling
• Rash, itchiness, blistering
• Systemic upset with high temperature, fever and rigors, vomiting and weakness

Additional information:

• Individuals with lymphoedema are at risk of cellulitis due to: compromised lymphatic and immune status; and stasis of protein-rich fluid in the tissues
• An obvious cause (previous history of cellulitis, puncture wound or wound infection) may or may not be evident
• Attacks can be variable in presentation in people with lymphoedema, and are sometimes referred to as acute inflammatory episodes.

Diagnosis is based on history and examination

Differential diagnosis:

• Severe stasis eczema
• Deep venous thrombosis
• Acute lipodermatosclerosis
• Early stage necrotising fasciitis
• Critical limb ischaemia (‘sunset foot’)
• Erysipelas
• Lymphangitis

Possible investigations to consider:

• C-Reactive protein (CRP)
• White cell count (WCC)
• Plasma viscosity
• Full blood count and routine biochemistry
• Blood glucose
• Antistreptolysin (ASO) titre
• Microbiology swab of skin breaks or blisters prior to starting antibiotics
• Mycology sample if tinea pedis or fungal nail infection present: skin scrapping and/or nail clippings

Additional information:

• Evidence indicates that most episodes of cellulitis in lymphoedema are caused by Group A Streptococci or Staphylococcus Aureus.

Moderate systemic signs: consider Out Patient Therapy rather than hospital admission in absence of:

• Severe localised pain
• Confusion
• Systolic BP <100mmHG
• Sepsis syndrome, any 2 of:
  • heart rate >100
  • resp rate>20/min
  • temp >38^oC or <36^oC
  • white cell count >12 or <4/mm³
• Rapidly evolving skin lesions or skin blistering

Hospital admission is required if the patient has:

• Severe systemic signs/sepsis syndrome, which may include:
  • Severe localised pain
  • Confusion
  • Systolic BP <100mmHG
  • Sepsis syndrome, any 2 of:
    • heart rate >100
    • resp rate>20/min
    • temp > 38^oC or <36^oC
    • white cell count >12 or <4/mm³
  • Rapidly evolving skin lesions or skin blistering
  • Vomiting
• Deteriorating local signs after first and second line antibiotics: may require IV antibiotics via OPAT or hospital admission.

• Closely monitor person for level of systemic upset
• Mark and date edge of the erythema using a soft-tipped pen (not ballpoint)
• Provide advice on self-care
  • Bed rest and elevation of the affected area/limb
  • Avoid compression garments during the acute attack; use as soon as comfortable and tolerated
  • Recommend analgesia, such as paracetamol; avoid NSAIDS during the acute attack (possible link to necrotizing fasciitis)
  • Resume normal levels of exercise when inflammation has reduced and person is comfortable
  • Return to work depends on the person’s occupation.

• Refer to OPAT team (Outpatient Antibiotic Therapy)
• IV Ceftriaxone 1g od as OPAT
• Poor response add oral clindamycin 600mg qds
• Daily review by OPAT team
• Mark and date edge of erythema to monitor extent and severity using soft- tipped pen (not ballpoint)
• Monitor bloods including C-Reactive Protein and Full Blood Count
• Provide advice on self-care
  • Bed rest and elevation of the affected area/limb
  • Avoid compression garments during the acute attack; use as soon as comfortable and tolerated
  • Recommend analgesia, such as paracetamol; avoid NSAIDS during the acute attack (possible link to necrotizing fasciitis)
  • Resume normal levels of exercise when inflammation has reduced and person is comfortable
  • Return to work depends on the person’s occupation.

Hospital therapy for IV antibiotics

• IV flucloxacillin 2g 6-hourly
• No/poor response after 48 hours: give clindamycin 600mg 6-hourly IV.
• Allergic to penicillin: give vancomycin IV according to NHS Highland vancomycin dosing guidelines. Seek advice from Microbiology prior to considering clindamycin 600mg 6-hourly IV
• Ano-genital cellulitis: give flucloxacillin 2g 6-hourly IV plus gentamicin 5mg/kg IV (as per NHS Highland gentamicin dosing guidelines) daily; adjust dose according to renal function and assay.

Additional care

• Monitor inflammatory markers (C-Reactive Protein, Plasma Viscosity, WCC)
• Full blood count and routine biochemistry
• Monitor vital signs
• Record baseline: extent and severity of rash; consider marking and dating the edge of the erythema using a soft-tipped pen (not ballpoint)
• Consider:
  • Blood cultures if evidence of sepsis
  • Microbiology swab of skin breaks or blisters prior to starting antibiotics
  • Blood glucose
  • Antistreptolysin titre (ASO)
  • Mycology sample if severe tinea pedis present or fungal nail infection: skin scrapping and/or nail clippings
• Provide advice on self-care
  • Bed rest and elevation of the affected area/limb
  • Avoid compression garments during the acute attack; use as soon as comfortable and tolerated
  • Recommend analgesia, such as paracetamol; avoid NSAIDS during the acute attack (possible link to necrotizing fasciitis)
  • Resume normal levels of exercise when inflammation has reduced and person is comfortable
  • Return to work depends on the person’s occupation.

Switch IV to oral treatment

Flucloxacillin 500mg 6-hourly, or clindamycin 300mg 6-hourly once:

• Temperature down for 48 hours
• Inflammation has resolved
• CRP is falling.

Continue oral antibiotics for at least 14 days after a definite clinical response has been observed, and until all signs of acute inflammation have resolved.

Additional information

• Some individuals require an extended period of oral antibiotic treatment
• Skin changes, discolouration or staining may persist for months or longer following severe cellulitis and do not necessarily require ongoing antibiotics
• Some individuals may require a supply of antibiotics to self-administer early

• First line antibiotic: oral flucloxacillin 500mg qds
• If allergic to penicillin: give clarithromycin 500mg bd or doxycycline 200mg stat, then 100mg bd.
• Second line antibiotic: if no/poor response (unresolved inflammation or developing systemic symptoms), change to clindamycin 300mg qds.

Additional information

Discuss with microbiologist if unresponsive to antibiotics or if unusual circumstances such as animal bite or lick preceded an attack.

IV to oral switch

Flucloxacillin 500mg 6-hourly, or clindamycin 300mg 6-hourly once:

• Temperature down for 48 hours
• Inflammation has resolved
• CRP is falling.

Continue oral antibiotics for at least 14 days after a definite clinical response has been observed, and until all signs of acute inflammation have resolved.

Additional information

• Some individuals require an extended period of oral antibiotic treatment
• Skin changes, discolouration or staining may persist for months or longer following severe cellulitis and do not necessarily require ongoing antibiotics
• Some individuals may require a supply of antibiotics to self-administer early in an attack.

Self-care advice and treatment to reduce the risk of cellulitis:

• Wash the skin daily and pat dry with a clean, soft towel
• Keep the skin well moisturised: daily use of a bland emollient such as Diprobase ® Cream or Epaderm ® Ointment (refer to Highland Formulary)
• Consider emollient bath additive with antimicrobials such as Emulsiderm ® OTC or similar shower gel such as Dermol ®
• Protect from burns, injury, bites, sunburn, scratches using appropriate skin cover, gardening gloves, and insect repellent
• Tinea pedis should be actively treated: application of terbinafine otc cream once or twice daily for two weeks (or refer to Highland Formulary). Follow by maintenance treatment, using cream or powder such as miconazole nitrate spray
• Fungal infection of nails: send nail clippings to mycology; consider amorolfine otc nail lacquer.
• Some patients who have had one or more episodes of cellulitis can benefit from “just in case” antibiotics or antibiotic prophylaxis (refer to recurrent cellulitis guidance)

Those at risk of further cellulitis episodes include individuals with:

• Skin and tissue problems: dermatitis, weeping eczema, open wounds
• Poorly managed oedema
• Tinea pedis and/or maceration between the toes
• Poorly resolved infection, due to inadequate length of antibiotic treatment.

British Lymphology Society: Guidelines on the management of cellulitis in lymphaedema. 

Cellulitis patient information leaflet