Lymphedema People Logo


Key Words:  Strep A,  Lymphedema,  Cellulitis,  Bacteremia,  Septicemia, Cutaneous lympatics, immunocompromised,  St. Anthony's Fire,  Staph aureus,  Strep G, Penicillin,  Probenecid, Dicloxacillin,  Erythromycin,  Keflex,  Augmentin,  Necrosis,  Gangrene,  Thrombophebitis, Bacterial endocarditis,  Soft tissue infections


Erysipelas (also called St. Anthony's Fire)is a superficial bacterial skin infection skin generally caused by Strep A bacteria or Strep B bacteria. It can spread with alarming rapidity as it invades the cutaneous lymphatics.

While some classify it as a "form of cellulitis," it actually can be differentiated by the clear lines of demarcation of the infection. Symptoms include marked lines of infection, fever, pain, an overall achy feeling and swollen lymph nodes. Most cases involve the legs, and the second largest number of cases involve the face.  However a delay in treatment can result in deeper cellulitis or lymphangitis.

Like any type of infection a lymphedema patient experiences, antibiotic treatment needs to start immediately so as to prevent septicemia or bacteremia.  As with any infection erysipelas present a serious threat due to the immunocompromised state of the lymphedemous limb and because possible fibrosis handicaps effective antibiotic therapy. Also, in lymphedema patients Staph aureus (not Strep A) has been implicated as the infective bacteria.

While very similar and often confused with actual cellulitis it can be differentiated by the raised borders and advancing edges. The most commonly affected body areas are the legs, followed by the face.

Risk Factors

There are a number of factors that might predispose one to erysipelas.  The primary cause of course is a break, cut or entry foci in the skin and subsequent infection usually by a Strep A bacterium.  Susceptibility factors include edema, lymphedema, venous insufficiency, venous stasis, dermatosis, diabetes, HIV infection, and other immunocompromising medical conditions.

Transmission factors include port of entry through nasal cavity, insect bites, cut, incisions.


The infection may start out as a inconspicuous small red patch and spread rapidly to a painful fiery red plaque.  The infection area will be warm or hot and quite tender.  Over-all body symptoms might include feeling unusually drained of energy, achiness, chills, fever and malaise. There may also be blisters on the infected area and possible red streaking. 


Treatment generally will involve the administration of an oral antibiotic.  The infection responds well to penicillin based antibiotic. In addition Probenecid may be used as it increase the effectiveness of penicillins. For more resistant infections dicloxacillin may be used.  Other antibiotics may include  Nafcillin, Erythromycin, Keflex and Augmentin.  

Depending upon the severity and spread IV antibiotic therapy may also be used for lymphedema patients.  Also, limiting one's activity with limb elevation is standard protcol.

Blood cultures and/or wound cultures may be needed to determine the exact bacteria involved. 


Complications may include bacteremia or septicemia, abscess, tissue necrosis (gangrene)in the most severe cases, thrombophlebitis, bacterial endorcarditis.


Prompt diagnosis and treatment will bring favorable results and in all but a very few patients recovery will be complete and without complications.  At risk groups, including those with lymphedema may experience recurrent episodes.




Erysipelas is a type of cellulitis (skin infection) generally caused group A streptococci..

Causes, incidence, and risk factors  

Erysipelas may affect both children and adults. The risk factors associated with this infection include local trauma (break in the skin), skin ulceration, and impaired venous or lymphatic drainage.

In the past, the face was most commonly involved yet now accounts for only up to 20% of cases. The lower extremities (legs) are affected in up to 80% of cases.


Signs and tests 

The diagnosis of erysipelas is based on the characteristic appearance of the skin lesion. Skin biopsies are usually not needed. Blood cultures are rarely positive (up to 5% of the time).


The cornerstone of therapy is treatment with antibiotics such as penicillin, which are active against streptococci. Depending on the severity, intravenous antibiotics may be used. In less severe cases, oral antibiotics may be sufficient. In individuals who have recurrent erysipelas, long-term antibiotics may be required.

Expectations (prognosis)

If appropriate antibiotic therapy is given early, the outcome is favorable. Skin changes may take up to a few weeks to normalize and peeling is common.

In some patients, streptococci may travel to the blood (bacteremia) and additional sites may be involved such as heart valves, joints, and bones


Calling your health care provider 

Call your health care provider if you have a skin lesion that has features of erysipelas.


Avoiding cuts and scrapes may reduce the risk for the development of erysipelas.

Update Date: 7/19/2002





Erysipelas, earlier named St Anthony's fire, is an acute superficial cellulitis characterized by a sharply demarcated advancing border surrounding raised, deeply erythematous, indurated painful skin involving the dermis, lymphatic, and superficial subcutaneous tissue. It is usually associate with a portal of entry. A number of clinical entities can present with similar lesions: the "slapped cheek" of erythema infectiosum (fifth disease), early herpes zoster involving the second division of the fifth cranial nerve before the vesicular eruption, contact dermatitis, insect bites, furunculosis, sialadenitis, impetigo, malar rash of systemic lupus erythematous, photodermatis, rosacia, Melkersson - Rosenthal syndrome, Sweet's syndrome, dermatomyositis and relapsing polychondritis.,

Although all ages are affected, erysipelas primarily is a disease of adults with a peak age of 60 to 80 years. Erysipelas classically involves the face; however, distribution patterns have changed, and lower extremities currently are the predominant location in 70 to 85 per cent of cases. It involves upper extremities in 2% to 10% of cases, face in 6% to 20%, and trunk and external genitalia is less than 2%. As far as the infrequently affected sites are concerned, one may observe erysipelas of the trunk following surgery, erysipelas of the abdomen in the neonate following infection of the umbilical stump, and erysipelas of the external genitalia as the result of an infected circumcision site. Other portals of entry include chronic leg ulcers, tinea pedis, insect bites, eczema, and venectomy for coronary artery bypass surgery.

In the majority of erysipelas cases, group A beta-hemolytic streptococci are the responsible organisms with group G streptococci being the second most frequent causative organism. However, group B and C streptococci, Staphylococcus aureus, Streptococcus pneumoniae, Hemophilus influenzae, and Yersinia enterocolitica have all been reported as etiologic organisms.

Patients may become bacteremic developing metastatic foci of infection. Infants are at particular risk for systemic spread. Complications such as sepsis, deep gangrene, abscess formation, or death due to systemic toxicity are more frequent in the immunocompromized patient. An intense treatment regimen is warranted in patients suffering from diabetes mellitus, cirrhosis, malignancies, and alcohol abuse. Cultures of tissue aspirate from the advancing border of the lesion and cultures of the nose and throat typically are positive for group A streptococci, as are blood cultures in septic patients. The laboratory evaluation usually shows an elevated white blood cell count with polymorphonuclear leukocytes and nonspecific signs of inflammation such as increased erythrocyte, sedimentation rate and elevated fibrinogen. Hematuria and proteinuria should be tested for at the initial presentation and approximately 3 weeks later to monitor development of acute glomerulonephritis.3

The clinical picture of erysipelas is so characteristic that streptococcal infection can be presumed and antimicrobial treatment initiated. The treatment of choice is penicillin. It can be administered intravenously, orally, or intramuscularly depending on severity of symptoms and patient reliability with a duration of treatment of at least 10 days. For the penicillin-allergic patient, erythromycin or cephalexin can be used.

In cases where coexistant disease is possible, broad spectrum antibiotics should be used pending cultures and clinical response. Since bacterial endocarditis must be considered in all IV drug abusers with fever, this patient is treated with naficllin 2 grams IV, gentamycin 120 mg IV and hospitalization.

Admission criteria include patients at the extremes of age, demonstrate systemic toxicity, immune compromise such as HIV disease, parenteral drug abuse, diabetes mellitus, or cancer.

Clinical Pearls:

1) Diagnosis is made on the characteristic clinical picture.

2) Features that help distinguish erysipelas are acute onset, erythema, warmth, edema, pain, fever, and isolated regional involvement with clearly demonstrated margins.6

3) Erysipelas in children, unless quite limited, requires hospitalization.

4) Treatment of choice is penicillin unless coexistant diseases mandate broad spectrum antibiotic coverage.

Author: J. Alan Morgan, DO, LTC, MC - Program Director -Joint Military Medical Centers of San Antonio - Emergency Medicine Residency - Brook Army Medical Center - Wilfor Hall Medical Center, Lacklan AF Base, Texas 78236-5300

*Link no longer available


Risk factors for erysipelas of the leg (cellulitis): case-control study

Alain Dupuy , senior resident a Hakima Benchikhi , dermatologist a Jean-Claude Roujeau , professor a Philippe Bernard , professor c Loïc Vaillant , professor d Olivier Chosidow , assistant professor e Bruno Sassolas , consultant f Jean-Claude Guillaume , consultant g Jean-Jacques Grob , professor h Sylvie Bastuji-Garin , assistant professor b

a Dermatology Department, Hôpital Henri Mondor, 94010 Créteil, France, b Public Health Department, Hôpital Henri Mondor, c Dermatology Department, Hôpital Robert Debré, 51092 Reims, France, d Dermatology Department, Hôpital Trousseau, 37044 Tours, France, e Dermatology Department, Hôpital Pitié-Salpêtrière, 75013 Paris, France, f Dermatology Department, Centre Hospitalier Universitaire de Brest, 29285 Brest, France, g Dermatology Department, Hôpital Pasteur, 68024 Colmar, France, h Dermatology Department, Hôpital Sainte-Marguerite, 13009 Marseille, France

Correspondence to: Dr Bastuji-Garinsylvie   Objective: To assess risk factors for erysipelas of the leg (cellulitis).
Design: Case-control study.
Setting: 7 hospital centres in France.
Subjects: 167 patients admitted to hospital for erysipelas of the leg and 294 controls.
Results: In multivariate analysis, a disruption of the cutaneous barrier (leg ulcer, wound, fissurated toe-web intertrigo, pressure ulcer, or leg dermatosis) (odds ratio 23.8, 95% confidence interval 10.7 to 52.5), lymphoedema (71.2, 5.6 to 908), venous insufficiency (2.9, 1.0 to 8.7), leg oedema (2.5, 1.2 to 5.1) and being overweight (2.0, 1.1 to 3.7) were independently associated with erysipelas of the leg. No association was observed with diabetes, alcohol, or smoking. Population attributable risk for toe-web intertrigo was 61%.
Conclusion: This first case-control study highlights the major role of local risk factors (mainly lymphoedema and site of entry) in erysipelas of the leg. From a public health perspective, detecting and treating toe-web intertrigo should be evaluated in the secondary prevention of erysipelas of the leg.


Commonly caused by streptococci, erysipelas is an infectious condition of the skin or subcutaneous tissue, which usually affects the leg (cellulitis).1-3 Although a potentially serious disease, erysipelas of the leg can be controlled with antibiotics. As recurrences of erysipelas are common and patients are usually admitted to hospital, cost is an important issue. The identification of risk factors for erysipelas is therefore critical in prevention of the disease.

Several factors, either local (for example, disruption of the cutaneous barrier, lymphoedema, venous insufficiency) or general (for example, diabetes mellitus, overweight, alcohol misuse), have been suspected as risk factors for erysipelas of the leg from a few case series.4-8 Owing to the inherent methodological limitations of such studies, however, these factors could not be assessed quantitatively---that is, compared with a control group. We conducted a case-control sudy to assess risk factors for erysipelas of the leg, particularly the role of toe-web intertrigo and other potential sites of entry.

Subjects and methods

Study design
We conducted our case-control study prospectively from June 1995 to October 1996 in seven hospital centres in France. Cases and controls were matched for age (range 5 years), sex, and hospital (admission within the same 2 month period). For a type 1 error of 0.05%, 130 cases were sufficient to detect, with a power of 80%, odds ratios >3.2 for factors with a prevalence of 5% in the general population (for example, venous insufficiency) or odds ratios >2.5 for factors with a prevalence of 10% in the general population (for example, toe-web intertrigo).

We included patients admitted consecutively to each of the participating centres for erysipelas of the leg. We excluded patients under 15 years of age and patients with abscess or necrotising fasciitis (defined by frank cutaneous necrosis on physical examination or fascial oedema and necrosis detected at surgery). Erysipelas was defined as the sudden onset (<24 hours) of a well demarcated cutaneous inflammation, with fever >38°C or chills. Our definition for erysipelas---that is, an acute bacterial dermohypodermatitis---corresponds to non-necrotising cellulitis in other countries or reports. Of the 178 patients recruited, 11 (6%) did not fulfil the inclusion criteria (8 had no fever or chills, and 3 had cellulitis elsewhere). The 167 cases comprised 87 men (52%) and 80 women (48%) (mean age 56.5 (SE 1.8) years). The right leg was affected in 85 cases (51%), the left in 78 (47%), and both in 4 (2%). Overall, 129 patients (77%) were admitted for newly diagnosed erysipelas of the leg, 8 (5%) for a first recurrence, 15 (9%) for a second recurrence, and 15 (9%) for a third or more recurrence.

We included two controls for each case matched for age, sex, and hospital, who were admitted for an acute condition not a priori related to one of the suspected risk factors nor related to a chronic disease. Among 323 potential controls, 21 (7%) were excluded because they did not fulfil the above criteria. The 294 controls comprised 154 men (52%) and 140 women (48%) (mean age 56.6 (1.1) years) who had been admitted for trauma (109, 37%), dermatological conditions (49, 17%), abdominal surgery (38, 13%), infection (30, 10%), orthopaedic surgery (13, 4%), vascular disease (6, 2%), sciatalgia (6, 2%), eye disease (2, 1%), and other conditions (41, 14%).

Data collection
One dermatologist in each centre conducted direct interviews with a structured questionnaire and performed the clinical examination of cases and controls. Besides age, sex, and current or past occupation, we assessed general and local potential risk factors. General risk factors included being overweight (>120% of the ideal weight as calculated by Lorentz's formula), diabetes mellitus, smoking (current smoker v non-smoker or past smoker), alcohol misuse (two items on the CAGE questionnaire9), and seated position at work. Local risk factors were a history of leg surgery, x ray therapy (inferior limb or pelvis), neurological disorders, leg thrombophlebitis, and leg ulcer. Leg oedema, lymphoedema, leg ulcer, pressure ulcer, leg dermatosis, toe-web intertrigo, varicose veins or varicosities, and peripheral pulses were detected by clinical examination. No laboratory investigations were performed.

Data analysis
We compared both general and local factors between cases and controls.

Venous insufficiency was defined as the presence of at least one of the following: history of either venous leg ulcer or leg phlebitis, or specific dermatitis. A site of entry was considered present if either a leg ulcer, a wound, an excoriated leg dermatosis, a pressure ulcer, or a toe-web intertrigo was present on a leg---whether or not erysipelas was present. Toe-web interspaces were evaluated as: 1, normal; 2, doubtful; 3, abnormal; or 4, fissurated. We considered intertrigo present with scores of 3 or 4 and absent with scores of 1 or 2.

In the analysis we included only cases with newly diagnosed erysipelas of the leg (129 patients).10 We retained the controls matched to recurrent cases for the unconditional analysis but discarded them for the conditional analysis. As the results of both analyses were similar, we present only the results of the unconditional analysis.

We conducted a standard case-control analysis.10 For each exposure we calculated odds ratios and 95% confidence intervals separately. We used unconditional logistic regression models and forced the matching variables into all models. For lateralised factors, we took into account only the ipsilateral side.

The factors we chose for inclusion in the multivariate model were selected by using multiple 2 × 2 analyses on those variables that emerged from the univariate analysis, and we assessed interaction and confounding by fitting multiplicative models. We then conducted a final backward step by step regression.

We conducted specific analyses for lateralised factors. These were defined as local factors that could be present on a patient's limb yet absent on the other---that is, history of phlebitis, leg ulcer, leg surgery, neurological disorders, x ray therapy, current lymphoedema, abolition of a peripheral pulse, and site of entry (leg ulcer, wound, pressure ulcer, excoriated leg dermatosis, toe-web intertrigo). With the hypothesis that a lateralised factor may be a site of entry if situated on the affected leg, we recorded these factors as ipsilateral (affected side) or contralateral (healthy leg) for cases. For controls, we arbitrarily determined an ipsilateral and a contralateral side in each patient thus allowing comparisons between cases and controls. We also compared ipsilateral and contralateral sides in cases by paired analysis.

In the interests of public health, we calculated population attributable risks as the fraction of the total disease experienced in the population that would not have occurred if the effect associated with the risk factor was absent. This took into account adjusted odds ratios and distribution of exposure among cases.11

We analysed the data with SAS-PC (version 6.12, SAS Institute, Cary, NC) and BMDP software (University of California, Berkeley).


Risk factors for erysipelas of the leg
In the univariate analysis, seated position at work, diabetes mellitus, alcohol misuse, and smoking were not associated with erysipelas of the leg (table 1), and these were not further analysed. We observed no association with a history of x ray therapy. The associations between erysipelas of the leg and the presence of either varicosities or a history of neurological disorders were close to significance.

Table 1. Univariate analysis of risk factors for erysipelas of the leg

Risk factors No (%) of cases (n=129) No (%) of controls (n=294) Odds ratio*
(95% CI)

Overweight 68 (53) 97 (33) 2.5 (1.6 to 3.9)
Seated position 13 (11) 26 (9) 1.0 (0.5 to 2.0)
Diabetes mellitus 16 (13) 24 (8) 1.7 (0.8 to 3.5)
Alcohol misuse 11 (9) 29 (10) 0.9 (0.4 to 2.0)
Smoking 26 (20) 77 (26) 0.6 (0.3 to 1.2)
Local risk factors
Leg oedema 48 (38) 44 (15) 3.6 (2.2 to 6.0)
Varicosities 55 (43) 110 (38) 1.5 (0.9 to 2.5)
History of:      
  Phlebitis  9 (13) 6 (2)  4.1 (1.4 to 11.6)
  Leg ulcer 15 (13) 5 (2)  8.3 (3.2 to 21.6)
  Leg surgery 36 (30) 41 (15) 2.7 (1.6 to 4.6)
  Neurological disorder 13 (10) 12 (4) 2.1 (0.9 to 5.0)
  x ray therapy 5 (4) 5 (2) 1.7 (0.5 to 5.8)
Lymphoedema 22 (18)   1 (0.4) 57.7 (16.9 to 197)
Abolition of a peripheral pulse 36 (30) 36 (13) 2.8 (1.5 to 4.9)
Leg ulcer 17 (14) 2 (1) 20.6 (6.7 to 63.0)
Wound 47 (38) 21 (8)  6.8 (4.0 to 11.7)
Pressure ulcer 5 (4) 2 (1)  6.0 (1.4 to 26.0)
Leg excoriated dermatosis 11 (9) 7 (3) 3.6 (1.4 to 9.2)
Toe-web intertrigo 83 (66) 65 (23)  6.6 (4.2 to 10.5)

Table 2 summarises the results of the multivariate analysis. Lymphoedema was the most prominent risk factor; the presence of a site of entry was also a strong risk factor. The risks associated with leg oedema and venous insufficiency were weaker; overweight was the only general risk factor associated with erysipelas of the leg.

Table 2. Multivariate analysis of risk factors for erysipelas of the leg

Risk factor Odds ratio* (95% CI)

Lymphoedema 71.2 (5.6 to 908)
Site of entry  23.8 (10.7 to 52.5)
Leg oedemadagger 2.5 (1.2 to 5.1)
Venous insufficiency 2.9 (1.0 to 8.7)
Overweight  2 (1.1 to 3.7)

* Adjusted for age, sex, hospital, and variables in table.
dagger Excluding oedema related to venous insufficiency.
The only two factors of significance between the cases admitted for recurrence and those admitted for a first episode were that patients admitted for recurrence were older (60.3 (2.4) v 56.5 (1.8)) and had a more frequent history of leg surgery (2.2; 1.1 to 4.7).

Lateralised factors
The analysis comparing both legs among cases showed that all the factors were more frequently present on the ipsilateral leg than on the contralateral leg, and statistical significance was reached only for history of phlebitis and history of x ray therapy (data not shown).

Table 3 compares the number of intertrigo in cases and controls. Before adjustment for number of toe-web intertrigo on the opposite foot, a significant risk was observed on both sides for one intertrigo, and this increased with the number of affected interspaces. After adjustment this relation remained unchanged on the ipsilateral side and disappeared on the contralateral side.

Risks associated with the site of entry
Site of entry was a strong risk factor for erysipelas of the leg (24.5; 11.0 to 54.9). We calculated multivariate estimates of odds ratios and population attributable risks associated with each type of site of entry. Leg ulcer (62.5; 7.0 to 556), toe-web intertrigo (13.9; 7.2 to 27.0), and traumatic wound (10.7; 4.8 to 23.8) exhibited strong and highly significant associations with erysipelas of the leg whereas pressure ulcer and excoriated leg dermatosis were not significant. The strongest odds ratio was for leg ulcer, although the population attributable risks associated with leg ulcer (14%) were much smaller than for intertrigo (61%) or wound (35%).


To our knowledge this is the first controlled study to examine risk factors for erysipelas of the leg. In our study, diabetes and alcohol misuse were not associated with erysipelas of the leg, and being overweight was the only general factor associated with the condition. We showed that lymphoedema and a site of entry were the main risk factors. Among the different potential sites of entry, toe-web intertrigo had the highest population attributable risk.

Our study has some limitations. Firstly, because our study was hospital based the recruitment of cases could be biased toward more severe disease or more disabled patients. But because no community based study of erysipelas of the leg is available, it was impossible for us to assess whether our cases had more specific risk factors than those patients not referred to hospital. We only assessed patients from dermatology units, and in some hospitals not all cases of erysipelas of the leg are admitted to such units, so referral bias due to concurrent dermatological conditions may have occurred. We do not, however, believe that toe-web intertrigo was a reason for referring patients with erysipelas of the leg to a dermatology unit. Hospital controls were chosen for logistic reasons as we believe that non-inclusion of patients admitted to hospital for a chronic disease or for a disease that could have been a priori related to a suspected risk factor, and recruitment from different surgical or medical units, were sufficient for obtaining an appropriate control group.12

With regard to assessment of exposure and information bias, our investigators were dermatologists who knew whether subjects were controls or cases. The questionnaire, however, was standardised and did not contain open questions. Potential observer bias for assessment of toe-web interspaces was prevented by grouping the four categories in the questionnaire to two for the analysis.

Finally, major confounders were taken into account by matching factors and by adjustment during analysis. For lateralised factors, we controlled for confusion bias for presence or absence of a risk factor on the opposite leg by specific analyses.

Risk factors for erysipelas of the leg
Local factors seemed to be the most important risk factors for erysipelas of the leg. Lymphoedema showed the greater risk, which was present in 18% of our cases---more than in most,4 6 8 but not all,13 prior series. Such a discrepancy may be due to the retrospective collection of data in prior studies or to differences in the definition of lymphoedema or lymphatic impairment. For most authors, lymphatic impairment plays a major role in the pathophysiology of erysipelas of the leg.1 13-15

A site of entry was found in almost all cases and could be considered as a requisite factor for the occurrence of a erysipelas of the leg. Toe-web intertrigo is mostly due to fungal infection (Tinea pedis), and its prevalence in the general population is probably higher than 10%.16 In previous case series of erysipelas of the leg, prevalence of intertrigo ranged between 6% and 26%,4-8 so whether toe-web intertrigo was a risk factor for erysipelas of the leg in these series was debatable. We showed a strong association between toe-web intertrigo and erysipelas of the leg. Toe-web intertrigo could have been linked to another general factor (for example, lack of hygiene) not listed in the questionnaire. The analysis with adjustment for intertrigo on the opposite foot ruled out such a hypothesis, and we concluded that intertrigo plays an exclusively local role. The credibility of the association between toe-web intertrigo and erysipelas of the leg is reinforced by the strength of the association and the relation between dose and effect (the odds ratios increased with the number of toe-web intertrigo on one foot). Because we systematically searched for toe-web intertrigo this may have explained its high prevalence (66%) in our study; a similar prevalence among cases was found in a prospective study.17 In our study, traumatic wound and leg ulcer were also strong risk factors for erysipelas of the leg. Lack of association with pressure ulcer and excoriated leg dermatosis may have been due to a lack of power, given the small number of patients exposed to risk.

Venous insufficiency was a significant risk factor for erysipelas of the leg although not as significant as the other risk factors. The definition of venous insufficiency is debatable, and as we chose ours on the basis of clinical findings only, this may have led to its underestimation. Interestingly, being overweight was the only general risk factor associated with erysipelas of the leg. In previously published case series, diabetes was present in 4.6% to 15% of cases4-8 and therefore was suspected as a risk factor. Our study had enough power (>80%) to detect an odds ratio >2.5 for prevalence of diabetes among controls. Similarly, we observed no association with alcohol misuse. Thus our findings exclude a strong association between either diabetes or alcohol misuse and erysipelas of the leg. These conclusions, however, do not apply to necrotic cellulitis, which we excluded from our study.

Consequences in clinical practice
The major concern in long term clinical management of patients with erysipelas of the leg is prediction and prevention of recurrences. As we restricted the analysis, because of methodological concerns,10 to cases with newly diagnosed erysipelas of the leg, we did not specifically study risk factors for recurrences. The prevalence of risk factors, however, was shown to be similar in cases of recurrence and first episodes, and it can be reasonably assumed that a patient with strong risk factors for a first episode also has a strong risk for recurrence if these factors remained unchanged. The prevention of recurrence is currently based on long term prophylactic antibiotherapy.18 19 Toe-web intertrigo is highly prevalent in the population, and the high population attributable risk of toe-web intertrigo in our study suggests that suppression of this factor would result in a dramatic decrease in incidence of erysipelas of the leg. The importance of treating toe-web intertrigo has been previously acknowledged20 21 but never assessed in a quantitative way. In contrast to leg ulcers or traumatic wounds, toe-web intertrigo is quite easy to avoid by detection and treatment. We therefore suggest that screening for, and treatment of, toe-web intertrigo should be a priority in subjects at high risk of erysipelas of the leg or in whom avoidance of recurrences is critical. Whether this strategy is sufficient alone or requires antibiotic prophylaxis needs to be ii

*Link no longer available


Selected Clinical Studies and Abstracts


A systematic review of bacteremias in cellulitis and erysipelas.

Feb 2012
Gunderson CG, Martinello RA.


Department of Internal Medicine and VA Connecticut Health Care System, Yale School of Medicine, 950 Campbell Avenue, West Haven CT 06516, USA; Veterans Health Administration, Public Health, 950 Campbell Avenue, West Haven CT 06516, USA.



Because of the difficulty of obtaining bacterial cultures from patients with cellulitis and erysipelas, the microbiology of these common infections remains incompletely defined. Given the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) over the past decade the proportion of infections due to S. aureus has become particularly relevant.


OVID was used to search Medline using the focused subject headings "cellulitis", "erysipelas" and "soft tissue infections". All references that involved adult patients with cellulitis or erysipelas and reported associated bacteremias and specific pathogens were included in the review.


For erysipelas, 4.6% of 607 patients had positive blood cultures, of which 46% were Streptococcus pyogenes, 29% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 11% were Gram-negative organisms. For cellulitis, 7.9% of 1578 patients had positive blood cultures of which 19% were Streptococcus pyogenes, 38% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 28% were Gram-negative organisms.


Although the strength of our conclusions are somewhat limited by the heterogeneity of included cases, our results support the traditional view that cellulitis and erysipelas are primarily due to streptococcal species, with a smaller proportion due to S. aureus. Our results also argue against the current distinction between cellulitis anderysipelas in terms of the relative proportion of infections due to S. aureus.

Science Direct


Erysipelas-like erythema as the presenting feature of familial Mediterranean fever.
Jan. 2012

Lidar M, Doron A, Barzilai A, Feld O, Zaks N, Livneh A, Langevitz P.


Rheumatology Unit and Medicine F, Heller Institute of Medical Research, Sheba Medical Center, Tel-Hashomer, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Department of Dermatology, Sheba Medical Center, Tel-Hashomer, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Medicine F, Heller Institute of Medical Research, Sheba Medical Center, Tel-Hashomer, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Rheumatology Unit, Heller Institute of Medical Research, Sheba Medical Center, Tel-Hashomer, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.



'Erysipelas-like' erythema (ELE) is a well recognized, although uncommon, manifestation of familial Mediterranean fever (FMF), which is frequently mistaken for infectious erysipelas, especially when forming the initial disease presentation. Aim  To clinically and genetically characterize ELE as the first manifestation of FMF. Methods  FMF patients with ELE as the first disease presentation (study group), were compared with FMF patients with ELE, appearing during the disease course (control group I), and to those FMF patients who never had ELE (control group II). Results  Patients of the study group were comparable to patients without ELE with respect to all demographic, clinical and genetic features studied, and yet differed from patients with ELE appearing later in the disease course in disease severity score (1.7 ± 0.4 vs. 2.4 ± 0.6, P = 0.01), length of diagnosis delay (7.2 ± 6.4 vs. 2.3 ± 3.3 years, P=0.037), age of FMF onset (24.8 ± 19.9 vs. 5.6 ± 5.7 years of age, P=0.014) and rate of homozygosity to the M694V mutation (14.3% vs. 68.7% respectively). ELE traits in the study and control groups were alike. Conclusions  FMF with ELE as the first disease manifestation form an uncommon subgroup, clinically and genetically diverging from the rest of the FMF-ELE patients.

Wiley Online


The effects of reduction operation with genital lymphedema on the frequency of erysipelas and the quality of life. 

Sept 2011

Zvonik M, Földi E, Felmerer G.


Division of Plastic Surgery, Department of Trauma Surgery, Plastic and Reconstruction Surgery, University Hospital Goettingen, Germany.


Genital lymphedema represents a severe disability for patients particularly when complicated by erysipelas, the most frequent complication. The objectives of this study were: to investigate the frequency of erysipelas in patients with genitallymphedema and genital lymphatic cysts who underwent evaluation for surgical treatment, to observe the influence of resection operations on the frequency of erysipelas, and to measure changes in the quality of life due to the resection. A total of 93 patients with genital lymphedema were studied. All patients underwent integrated care treatment in the Földi Clinic, Hinterzarten and the Department of Plastic and Hand Surgery of the University Hospital Freiburg during the period between 1997 and 2007. 44 of these patients underwent surgical treatment of genital lymphedema. The results indicate that lymphatic cysts were the most important risk-aggravating factor for recurrent erysipelas with lymphorrhea in the genital region (p < 0.001). Following the resection operation, however, the number of erysipelas incidents significantly decreased (p < 0.001). In addition, the antibiotic dose could be reduced after surgery (p = 0.039) and an improved quality of life was achieved (p < 0.001).



Erysipelas: a common potentially dangerous infection

Acta Dermatovenerol Alp Panonica Adriat. 2007 Sep

Celestin R, Brown J, Kihiczak G, Schwartz RA.

New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103-2714, USA.

Erysipelas is an acute superficial cutaneous cellulitis that commonly occurs not only in elderly and immunocompromised persons, but also in neonates and small children subsequent to bacterial inoculation through a break in the skin barrier. Group A Beta-hemolytic streptococcus (GABHS, Streptoccocus pyogenes) is the usual etiologic agent. Factors that predispose pediatric patients to the development of erysipelas include very young age, diabetes mellitus, an immunocompromised state, and nephrotic syndrome. Patients typically have a well-demarcated, erythematous, indurated, rapidly spreading patch with a palpable advancing border on the face or extremities. Fever with chills and general malaise may be prominent symptoms. Antibiotics are usually effective. Patients handled in a timely manner tend to recover without problems. However, potential complications include abscess formation, necrotizing fasciitis, septicemia, recurrent infection, and lymphedema.



Erysipelas as a sign of subclinical primary lymphoedema: a prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg.

Br J Dermatol. 2008 Mar 20

Damstra RJ, van Steensel MA, Boomsma JH, Nelemans P, Veraart JC.

Department of Dermatology, Phlebology and Lymphology, Nij Smelinghe Hospital, 9202 NN Drachten, The Netherlands.

Background: Erysipelas is a common skin infection that is usually caused by beta-haemolytic group A streptococci. After having had erysipelas in an extremity, a significant percentage of patients develops persistent swelling or suffers from recurrent erysipelas. We hypothesize that in cases of erysipelas without a clear precipitating agent, subclinical pre-existing congenital or acquired disturbances in the function of the lymphatic system are present. The persistent swelling after erysipelas is then most likely caused by lymphoedema. 

Objectives: We designed a study to examine if erysipelas of unknown origin is associated with a pre-existent insufficiency of the lymphatic system. If our hypothesis is correct, patients with erysipelas of unkown cause without previously evident lymphoedema should have evidence of disturbed lymphatic transport in the unaffected extremity. 

Methods: A prospective study, in which lymphoscintigraphy of both legs was performed in patients 4 months after presenting with an episode of erysipelas only in one leg. No patient had any known risk factor for erysipelas, such as diabetes mellitus, chronic venous insufficiency or clinical signs of lymphoedema. 

Lymphoscintigraphy was performed in 40 patients by subcutaneous injection of Tc-99m-labelled human serum albumin in the first web space of both feet. After 30 and 120 min, quantitative and qualitative scans were performed using a computerized gamma camera. During the lymphoscintigraphy, the patients performed a standardized exercise programme. Lymph drainage was quantified as the percentage uptake of Tc-99m-labelled human serum albumin in the groin nodes at 2 h after injection. Groin uptake of < 15% is pathological; uptake between 15-20% is defined as borderline, and uptake of > 20% as normal.

Results: The mean +/- SD percentage uptake in the groin nodes in the affected limbs was 9.6 +/- 8.5% vs. 12.1% +/- 8.9% in the nonaffected limbs. The mean paired difference in uptake between the nonaffected vs. affected side was 2.5% (95% confidence interval 1.1-3.9%). This indicates that lymphatic drainage in the nonaffected limb was only slightly better than in the affected limb despite the infectious event in the latter. Of 33 patients with objective impairment of lymph drainage in the affected limb, 26 (79%) also had impaired lymph drainage in the nonaffected limb. Agreement in qualitative measurements between affected and nonaffected leg was less pronounced: 21 patients had abnormal qualitative results in the affected leg of whom nine also had impairment of the nonaffected leg (43%). 

Conclusions: Erysipelas is often presumed to be purely infectious in origin, with a high rate of recurrence and a risk of persistent swelling due to secondary lymphoedema. In this study, we show that patients presenting with a first episode of erysipelas often have signs of pre-existing lymphatic impairment in the other, clinically nonaffected, leg. This means that subclinical lymphatic dysfunction of both legs may be an important predisposing factor. Therefore, we recommend that treatment of erysipelas should focus not only on the infection but also on the lymphological aspects, and long-standing treatment for lymphoedema is essential in order to prevent recurrence of erysipelas and aggravation of the pre-existing lymphatic impairment. Our study may change the clinical and therapeutic approach to erysipelas as well as our understanding of its aetiology

Blackwell Synergy


Erysipelas today

Med Pregl. 2007 May-Jun

Gvozdenović E, Dulović O.

Klinicki centar Srbije, Beograd. elika@eunet.yu

INTRODUCTION: Erysipelas is a form of cellulitis and a bacterial infection affecting the most superficial layers of the skin which is caused by group A--hemolytic Streptococcus. The symptoms of erysipelas usually arise quite suddenly and they are often accompanied by fever, chill and shivering. The affected skin is distinguished from other forms of cellulitis by well-defined, raised edge. The affected skin is red, swollen and may be finely dimpled (like an orange skin). 

TREATMENT OF ERYSIPELAS: Uncomplicated erysipelas can be treated on an outpatient basis. Indications for hospitalization include a severe clinical picture and socioeconomics factors. Most patients suffering from erysipelas in Belgrade are treated at the Institute of Infectious and Tropical Diseases, and the aim of this study was to analyze patients treated during 2002 and 2003, in order to determine characteristics of erysipelas at the beginning of the XXI century. 

MATERIAL AND METHODS: During the studied period, we treated 60 patients (26.7%) of all registrated erysipelas cases in Belgrade. The male/female ratio was 1:1.6. 

DISCUSSION AND CONCLUSION: Prevalence was higher during the summer months. In most cases, the severity and the need for hospitalization were recognized at the beginning; therefore, 74% of patients were hospitalized during the first five days from the onset of nonspecific signs of illness. Laboratory tests showed mild leukocytosis (med 12.05 x 10/9/l), with predominant neutrophils (74.8%) and increased fibrinogen (med 5.4 g/l). Predisposing factors were present in 83.3% of cases; of them, in 35% of cases this was not the first episode of this illness. In 85% of cases erysipelas of the leg was established, and it was the most frequent localization of all.



T-cell responsiveness to specific group A streptococcus antigens in patients with primary erysipelas

Klin Lab Diagn. 2007 Nov

Iudina IuV, Belaia OF, Pak SG.

Peripheral blood leukocytic migratory activity (LMA) was studied in 63 patients with primary erysipelas. To reveal LMA, a screening cell migration test (SCMT) was used as an indicator of the cooperation of T- and B-lymphocytes and macrophages in the stimulation with polysaccharide A, surface proteins, L-antigen, hyaluronidase, streptolysin O, a complete S. pyogenes antigen complex after Grasse. The prognostic value of MAL parameters was established at week 1 after the onset of erysipelas. A rapid transition of LMA from the phase of acceleration to that of inhibition was shown to characterize the formation of an adequate response, to correspond to the good course of the disease, and to be followed by the low likelihood of recurrences. The probability of a subsequent recurrence is much higher than that when LMA tends to transit from suppression to acceleration and when LMA parameters are constant in the phase of suppression or acceleration. No transition of LMA to the phase of suppression in early convalescence suggests that the formation of an immune response to streptococcus is delayed.



Erysipelas--course of disease, recurrence, complications; a 10 years retrospective study

Przegl Epidemiol. 2007

Wojas-Pelc A, Alekseenko A, Jaworek AK.

Katedra i Klinika Dermatologii Collegium Medicum Uniwersytetu Jagiellońskiego w Krakowie.

OBJECT: we studied erysipelas by conducting a retrospective analysis of 319 patients with erysipelas treated in Dermatology Department Jagiellonian University in Krakow between 1994 and 2004. 

METHODS: we performed a retrospective analysis of 319 patients hospitalized for erysipelas in our institution during a 10 year period. The statistical significance was examined by chi square and Kruskal-Wallis test (significant value p< or =0.05).

RESULTS: there were 35% males and 65% females patients. Median age was 63 years. Most of the female patients were pensioners (32.7%), most of the male patients were physical workers (40.5%). Summer time was the most frequent season for hospitalization (32.3%), and winter time was the rarest (17%). Most of the erysipelas has involved the lower limb (59.2%). There was significant dependence between the regional risk factors and occupation. The recurrent cases occurred in 67.3% cases with lower limb localisation in 69.44% cases. The most rare recurrent cases found on upper limb (6%). The systemic risk factors were associated with recurrent erysipelas in 69.44%. Complications, such as abscess formation, lymphangitis, venous insufficiency, osteitis, arthritis, septic tendonitis and elephantiasis were found in 25%.

 CONCLUSIONS: after review of the literature and our experiences it is clear that there is a strong need for interdisciplinary treatment to avoid various potential complications of erysipelas.


====External Links===================

Erysipelas outbreaks in Chile 

Apr 2011



Erysipelas and Lymphedema


Survey of general practitioners management of erysipelas Dec 2011

Science Direct


A systematic review of bacteremias in cellulitis and erysipelas. Nov 2011


Erysipelas in the elderly: Are the concerns and economic burden increasing? Apropos of a case.  June 2011


Local complications of erysipelas: a study of associated risk factors. June 2011


Erysipelas-like erythema with familial Mediterranean fever. May 2011


Erysipelas outbreaks in Chile Apr 2011


Analysis of epidemiology, clinical features and management of erysipelas. Sept 2010


Severe Leg Erysipelas


Diagnostic Images


External Links:

Erysipelas: a common potentially dangerous infection


Erysipelas after breast cancer treatment (26 cases).


Recurrent Erysipelas: 47 Cases


Recurrent erysipelas despite antibiotic prophylaxis: an analysis from case studies.





Synonyms and related keywords: group A beta-hemolytic streptococci, hemolytic streptococcus


Erysipelas br /





Also includes images


Diagnostic Images


Classification and External Resources

ICD-10 A46.0
Excludes: postpartum or puerperal erysipelas ( O86.8 )
ICD-9 035 -Erysipelas (gangrenous) (infantile) (newborn) (phlegmonous) (suppurative) 035 
  • 035 is a specific code that can be used to specify a diagnosis
  • 035 contains 9 index entries

035 excludes:

  • postpartum or puerperal erysipelas (670)
DiseasesDB 4428
MedlinePlus 000618
eMedicine derm/129 
MeSH D004886


Related Lymphedema People Medical Blogs:

Antibiotic Therapy, Types of Antibiotics

Bacterial Infections



MRSA Information

Antibiotic Glossary


Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.


Pat O'Connor

Lymphedema People / Advocates for Lymphedema


For information about Lymphedema\

For Information about Lymphedema Complications

For Lymphedema Personal Stories

For information about How to Treat a Lymphedema Wound

For information about Lymphedema Treatment

For information about Exercises for Lymphedema

For information on Infections Associated with Lymphedema

For information on Lymphedema in Children

Lymphedema Glossary


Lymphedema People - Support Groups


Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.



Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

Come join, be a part of the family!




If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.



All About Lymphangiectasia

Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.



Lymphatic Disorders Support Group @ Yahoo Groups

While we have a number of support groups for lymphedema... there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.


Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.



Lymphedema People New Wiki Pages

Have you seen our new “Wiki” pages yet?  Listed below are just a sample of the more than 140 pages now listed in our Wiki section. We are also working on hundred more.  Come and take a stroll! 

Lymphedema Glossary 


Arm Lymphedema 

Leg Lymphedema 

Acute Lymphedema 

The Lymphedema Diet 

Exercises for Lymphedema 

Diuretics are not for Lymphedema 

Lymphedema People Online Support Groups 



Lymphedema and Pain Management 

Manual Lymphatic Drainage (MLD) and Complex Decongestive Therapy (CDT) 

Infections Associated with Lymphedema 

How to Treat a Lymphedema Wound 

Fungal Infections Associated with Lymphedema 

Lymphedema in Children 


Magnetic Resonance Imaging 

Extraperitoneal para-aortic lymph node dissection (EPLND) 

Axillary node biopsy

Sentinel Node Biopsy

 Small Needle Biopsy - Fine Needle Aspiration 

Magnetic Resonance Imaging 

Lymphedema Gene FOXC2

 Lymphedema Gene VEGFC

 Lymphedema Gene SOX18

 Lymphedema and Pregnancy

Home page: Lymphedema People

Page Updated: Feb. 1, 2012