Erysipelas () is a relatively common bacterial infection of the superficial layer of the skin ( upper dermis), extending to the superficial

lymphatic vessels The lymphatic vessels (or lymph vessels or lymphatics) are thin-walled vessels (tubes), structured like blood vessels, that carry lymph. As part of the lymphatic system, lymph vessels are complementary to the cardiovascular system. Lymph vessel ...

within the skin, characterized by a raised, well-defined, tender, bright red rash, typically on the face or legs, but which can occur anywhere on the skin. It is a form of

cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of t ...

and is potentially serious. Erysipelas is usually caused by the bacterium ''

Streptococcus pyogenes ''Streptococcus pyogenes'' is a species of Gram-positive, aerotolerant bacteria in the genus ''Streptococcus''. These bacteria are extracellular, and made up of non-motile and non-sporing cocci (round cells) that tend to link in chains. They are ...

'', also known as ''group A β-hemolytic streptococci'', which enters the body through a break in the skin, such as a scratch or an insect bite. It is more superficial than

and is typically more raised and demarcated. The term comes from the

Greek Greek may refer to: Greece Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group. *Greek language, a branch of the Indo-European language family. **Proto-Greek language, the assumed last common ancestor ...

ἐρυσίπελας (''erysípelas''), meaning red skin. In animals erysipelas is a disease caused by infection with the bacterium ''

Erysipelothrix rhusiopathiae ''Erysipelothrix rhusiopathiae'' is a Gram-positive, catalase-negative, rod-shaped, non-spore-forming, nonacid-fast, nonmotile bacterium. Distributed worldwide, ''E. rhusiopathiae'' is primarily considered an animal pathogen, causing the diseas ...

''. In animals it is called Diamond Skin Disease and occurs especially in pigs. Heart valves and skin are affected. ''Erysipelothrix rhusiopathiae'' can also infect humans but in that case the infection is known as

erysipeloid In humans, ''Erysipelothrix rhusiopathiae'' infections most commonly present in a mild cutaneous form known as erysipeloid or fish poisoning. ''E. rhusiopathiae'' can cause an indolent cellulitis, more commonly in individuals who handle fish and ...

and is an occupational skin disease.

Signs and symptoms

Symptoms often occur suddenly. Affected individuals may develop a fever,

shivering Shivering (also called shuddering) is a bodily function in response to cold and extreme fear in warm-blooded animals. When the core body temperature drops, the shivering reflex is triggered to maintain homeostasis. Skeletal muscles begin to s ...

chills Chills is a feeling of coldness occurring during a high fever, but sometimes is also a common symptom which occurs alone in specific people. It occurs during fever due to the release of cytokines and prostaglandins as part of the inflammatory r ...

fatigue Fatigue describes a state of tiredness that does not resolve with rest or sleep. In general usage, fatigue is synonymous with extreme tiredness or exhaustion that normally follows prolonged physical or mental activity. When it does not resolve ...

headaches Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a result of m ...

and vomiting and be generally unwell within 48 hours of the initial infection. The

red Red is the color at the long wavelength end of the visible spectrum of light, next to orange and opposite violet. It has a dominant wavelength of approximately 625–740 nanometres. It is a primary color in the RGB color model and a secondar ...

plaque Plaque may refer to: Commemorations or awards * Commemorative plaque, a plate or tablet fixed to a wall to mark an event, person, etc. * Memorial Plaque (medallion), issued to next-of-kin of dead British military personnel after World War I * Pla ...

enlarges rapidly and has a sharply demarcated, raised edge. It may appear swollen, feel firm, warm and tender to touch and have a consistency similar to orange peel. Pain may be extreme. More severe infections can result in

vesicles Vesicle may refer to: ; In cellular biology or chemistry * Vesicle (biology and chemistry), a supramolecular assembly of lipid molecules, like a cell membrane * Synaptic vesicle ; In human embryology * Vesicle (embryology), bulge-like features o ...

(pox or insect bite-like marks),

blister A blister is a small pocket of body fluid (lymph, serum, plasma, blood, or pus) within the upper layers of the skin, usually caused by forceful rubbing (friction), burning, freezing, chemical exposure or infection. Most blisters are filled wi ...

s, and

petechia A petechia () is a small red or purple spot (≤4 mm in diameter) that can appear on the skin, conjunctiva, retina, and Mucous membrane, mucous membranes which is caused by haemorrhage of capillaries. The word is derived from Italian , 'freckle,' ...

e (small purple or red spots), with possible skin

necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...

(death).

Lymph node A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that inclu ...

s may be swollen and

lymphedema Lymphedema, also known as lymphoedema and lymphatic edema, is a condition of localized swelling caused by a compromised lymphatic system. The lymphatic system functions as a critical portion of the body's immune system and returns interstitial fl ...

may occur. Occasionally a red streak extending to the lymph node can be seen. The infection may occur on any part of the skin, including the face, arms, fingers, legs and toes; it tends to favour the extremities. The umbilical stump and sites of lymphoedema are also common sites affected. Fat tissue and facial areas, typically around the eyes, ears and cheeks, are most susceptible to infection. Repeated infection of the extremities can lead to chronic swelling (

lymphoedema Lymphedema, also known as lymphoedema and lymphatic edema, is a condition of localized swelling caused by a compromised lymphatic system. The lymphatic system functions as a critical portion of the body's immune system and returns interstitial fl ...

). File:Erysipel2.JPG, Erysipelas (ear) image:Erysipel.JPG, Erysipelas (arm) image:Erysipelas in a foot.jpg, Erysipelas (leg) File:Recurrent erysipelas on edematous leg.jpg, Recurrent erysipelas

Cause

Most cases of erysipelas are due to ''

'', also known as ''group A β-hemolytic streptococci'', less commonly to group C or G streptococci and rarely to ''

Staphylococcus aureus ''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often positive ...

''. Newborns may contract erysipelas due to ''

Streptococcus agalactiae ''Streptococcus agalactiae'' (also known as group B streptococcus or GBS) is a gram-positive coccus (round bacterium) with a tendency to form chains (as reflected by the genus name ''Streptococcus''). It is a beta-hemolytic, catalase-negative, a ...

'', also known as ''group B streptococcus'' or GBS. The infecting bacteria can enter the skin through minor trauma, human, insect or animal bites, surgical incisions, ulcers, burns and abrasions. There may be underlying

eczema Dermatitis is inflammation of the Human skin, skin, typically characterized by itchiness, erythema, redness and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become lichenification, thick ...

athlete's foot Athlete's foot, known medically as ''tinea pedis'', is a common skin infection of the feet caused by a fungus. Signs and symptoms often include itching, scaling, cracking and redness. In rare cases the skin may blister. Athlete's foot fungus m ...

(tinea pedis), and it can originate from streptococci bacteria in the subject's own nasal passages or ear. The rash is due to an

exotoxin An exotoxin is a toxin secreted by bacteria. An exotoxin can cause damage to the host by destroying cells or disrupting normal cellular metabolism. They are highly potent and can cause major damage to the host. Exotoxins may be secreted, or, simi ...

, not the ''Streptococcus'' bacteria, and is found in areas where no symptoms are present, e.g. the infection may be in the nasopharynx, but the rash is found usually on the epidermis and superficial lymphatics.

Diagnosis

Erysipelas is usually diagnosed by the clinician looking at the characteristic well-demarcated rash following a history of injury or recognition of one of the risk factors. Tests, if performed, may show a high white cell count, raised CRP or positive

blood culture A blood culture is a medical laboratory test used to detect bacteria or fungi in a person's blood. Under normal conditions, the blood does not contain microorganisms: their presence can indicate a bloodstream infection such as bacteremia or f ...

identifying the organism. Skin cultures are often negative. Erysipelas must be differentiated from

herpes zoster Shingles, also known as zoster or herpes zoster, is a viral disease characterized by a painful skin rash with blisters in a localized area. Typically the rash occurs in a single, wide mark either on the left or right side of the body or face. ...

angioedema Angioedema is an area of swelling ( edema) of the lower layer of skin and tissue just under the skin or mucous membranes. The swelling may occur in the face, tongue, larynx, abdomen, or arms and legs. Often it is associated with hives, which ...

contact dermatitis Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes are ...

, erythema chronicum migrans of early Lyme disease, gout, septic arthritis, septic bursitis, vasculitis, allergic reaction to an insect bite, acute drug reaction, deep vein thrombosis and diffuse inflammatory carcinoma of the breast.

Differentiating from cellulitis

Erysipelas can be distinguished from cellulitis by two particular features: its raised advancing edge and its sharp borders. The redness in cellulitis is not raised and its border is relatively indistinct. Bright redness of erysipelas has been described as a third differentiating feature. Erysipelas does not affect subcutaneous tissue. It does not release

pus Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection ...

, only serum or

serous fluid In physiology, serous fluid or serosal fluid (originating from the Medieval Latin word ''serosus'', from Latin ''serum'') is any of various body fluids resembling Serum (blood), serum, that are typically pale yellow or transparent and of a benign ...

. Subcutaneous

edema Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's Tissue (biology), tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels t ...

may lead the physician to misdiagnose it as

Treatment

Treatment is with

antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention o ...

; (

amoxicillin/clavulanic acid Amoxicillin/clavulanic acid, also known as co-amoxiclav or amox-clav, sold under the brand name Augmentin, among others, is an antibiotic medication used for the treatment of a number of bacterial infections. It is a combination consisting of a ...

cefalexin Cefalexin, also spelled cephalexin, is an antibiotic that can treat a number of bacterial infections. It kills gram-positive and some gram-negative bacteria by disrupting the growth of the bacterial cell wall. Cefalexin is a beta-lactam antibi ...

, or

cloxacillin Cloxacillin is an antibiotic useful for the treatment of a number of bacterial infections. This includes impetigo, cellulitis, pneumonia, septic arthritis, and otitis externa. It is not effective for methicillin-resistant ''Staphylococcus aureus ...

) taken by mouth for five-days; though sometimes longer. Because of the risk of reinfection, prophylactic antibiotics are sometimes used after resolution of the initial condition.

Prognosis

The disease prognosis includes: * Spread of infection to other areas of body can occur through the bloodstream (

bacteremia Bloodstream infections (BSIs), which include bacteremias when the infections are bacterial and fungemias when the infections are fungal, are infections present in the blood. Blood is normally a sterile environment, so the detection of microb ...

), including

septic arthritis Acute septic arthritis, infectious arthritis, suppurative arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, hea ...

Glomerulonephritis Glomerulonephritis (GN) is a term used to refer to several kidney diseases (usually affecting both kidneys). Many of the diseases are characterised by inflammation either of the glomeruli or of the small blood vessels in the kidneys, hence the ...

can follow an episode of streptococcal erysipelas or other skin infection but not

rheumatic fever Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops two to four weeks after a streptococcal throat infection. Signs and symptoms include fever, multiple painful jo ...

. * of infection: Erysipelas can recur in 18–30% of cases even after antibiotic treatment. A chronic state of recurrent erysipelas infections can occur with several predisposing factors, including alcoholism,

diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...

and athlete's foot. Another predisposing factor is chronic cutaneous

, such as can in turn be caused by venous insufficiency or heart failure. * Lymphatic damage *

Necrotizing fasciitis Necrotizing fasciitis (NF), also known as flesh-eating disease, is a bacterial infection that results in the death of parts of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms usually include red or p ...

, commonly known as ‘flesh-eating’ bacterial infection, is a potentially deadly exacerbation of the infection if it spreads to deeper tissue.

Epidemiology

There is currently no validated recent data on the worldwide incidence of erysipelas. From 2004 to 2005 UK hospitals reported 69,576 cases of cellulitis and 516 cases of erysipelas. One book stated that several studies have placed the prevalence rate between one and 250 in every 10,000 people. The development of antibiotics, as well as increased sanitation standards, has contributed to the decreased rate of incidence. Erysipelas caused systemic illness in up to 40% of cases reported by UK hospitals and 29% of people had recurrent episodes within three years. Anyone can be infected, although incidence rates are higher in infants and elderly. Several studies also reported a higher incidence rate in women. Four out of five cases occur on the legs, although historically the face was a more frequent site. Risk factors for developing the disease include * Arteriovenous fistula * Chronic skin conditions such as psoriasis, athlete's foot, and eczema * Excising the saphenous vein * Immune deficiency or compromise, such as ** Diabetes ** Alcoholism ** Obesity ** Human immunodeficiency virus (HIV) * In newborns, exposure of the umbilical cord and vaccination site injury * Issues in lymph or blood circulation * Leg ulcers * Lymphatic edema * Lymphatic obstruction * Lymphoedema * Nasopharyngeal infection * Nephrotic syndrome * Pregnancy * Previous episode(s) of erysipelas * Toe web intertrigo * Traumatic wounds * Venous insufficiency or disease

Preventive measures

Individuals can take preventive steps to decrease their risk of catching the disease. Properly cleaning and covering wounds is important for people with an open wound. Effectively treating athlete's foot or eczema if they were the cause of the initial infection will decrease the chance of the infection occurring again. People with diabetes should pay attention to maintaining good foot hygiene. It is also important to follow up with doctors to make sure the disease has not come back or spread. About one third of people who have had erysipelas will be infected again within three years. Rigorous antibiotics may be needed in the case of recurrent bacterial skin infections.

Notable cases

* In Rodrigo Souza Leão's autobiographical novel All Dogs are Blue, he says that his erysipelas is cured by the antibiotic Benzetacil (

Benzathine benzylpenicillin Benzathine benzylpenicillin, also known as benzathine penicillin G, is an antibiotic medication useful for the treatment of a number of bacterial infections. Specifically it is used to treat strep throat, diphtheria, syphilis, and yaws. It is a ...

).Souza Leão, Rodrigo (2013). ''All Dogs are Blue''. High Wycombe: And Other Stories. . p. 49.