Erysipelas is an acute bacterial skin infection that affects the upper dermis and the superficial lymphatic vessels. It presents as a raised, well-defined, bright red patch of inflamed skin. Most commonly, erysipelas occurs on the face or lower legs, and it is often accompanied by fever and other systemic symptoms. The condition is more superficial than cellulitis and can usually be distinguished by its sharp margins and rapid onset. 

While erysipelas can affect people of any age, it tends to occur more frequently in infants, young children, and older adults. Recurrence is common, particularly in individuals with risk factors such as chronic venous insufficiency, obesity, or impaired lymphatic drainage. Understanding the clinical presentation and associated risks is key to ensuring timely diagnosis and treatment. 

Erysipelas is a superficial form of cellulitis that primarily involves the skin’s upper layers and the associated lymphatics. The name comes from the Greek words “erythros” (red) and “pella” (skin), describing its vivid red appearance. The infection is usually abrupt in onset and can spread rapidly. 

It is characterized by an intensely red, shiny, swollen area of skin that is raised and clearly demarcated from the surrounding tissue. Inflammation often progresses over hours and may cause alarm due to its rapid spread. The raised border is due to lymphatic involvement, and systemic symptoms like fever tend to appear early in the course of the disease. 

Erysipelas is caused by certain types of bacteria that penetrate the skin through small breaks or injuries. The most common pathogens are beta-hemolytic streptococci, which are known for their ability to spread rapidly in superficial skin layers and provoke a strong immune response. Understanding the typical bacteria involved and how they enter the body helps guide effective treatment and prevention strategies. 

The most common bacteria responsible include: 

• Group A Streptococcus (Streptococcus pyogenes) — most common 

• Group G or Group C Streptococcus — less frequent 

• Group B Streptococcus — seen in neonates 

• Staphylococcus aureus — rarely a primary cause but may co-infect 

Bacteria typically gain entry through: 

• Minor trauma (e.g., cuts or abrasions) 

• Fissures, especially between the toes 

• Ulcers or surgical wounds 

• Insect bites 

• Skin conditions such as tinea pedis or eczema 

In neonates, group B streptococcus may enter through the umbilical stump. In adults, procedures like lymph node dissection that affect lymphatic drainage can increase susceptibility to infection.

The likelihood of developing erysipelas increases when certain conditions compromise the skin’s integrity or immune defenses. Understanding these risk factors is important for both prevention and management of the condition. 

Several factors increase susceptibility to erysipelas: 

• Disrupted skin barrier: Cuts, ulcers, eczema, or fungal infections 

• Lymphatic or venous issues: Lymphedema or chronic venous insufficiency 

• Systemic conditions: Diabetes mellitus, obesity, immunosuppression, alcoholism 

• Age-related vulnerability: Infants and older adults 

Poor hygiene, especially in those with limited mobility or in resource-constrained environments, can also contribute to an increased risk of infection. 

The condition begins when bacteria penetrate through a small break in the skin. Once inside, they multiply and release toxins, prompting an immune response: 

• Streptococcal toxins cause dermal inflammation 

• Superficial lymphatics become inflamed, leading to swelling 

• Capillary leakage results in redness and induration 

• Cytokine release causes systemic symptoms like fever 

This cascade of events results in the classic appearance and systemic features of erysipelas. Some toxins act as superantigens, causing more pronounced symptoms such as fever and hypotension. 

Erysipelas can present with a variety of systemic symptoms that reflect the body’s response to infection. These symptoms typically appear suddenly and are often the first signs of illness in affected individuals. 

Systemic symptoms 

• Sudden high fever (above 101.3°F) 

• Chills and malaise 

• Headache and nausea 

Skin findings 

• Bright red, shiny, raised skin lesion 

• Well-defined, sharp edges 

• Warmth and tenderness 

• Possible blistering or vesicle formation 

• Peau d’orange (orange peel-like appearance) 

• Regional lymph node swelling 

Common sites 

• Face (especially cheeks and nose) 

• Lower limbs (most frequent today) 

• Upper limbs (often post-surgical) 

In cases involving the face, symptoms may be linked to a preceding streptococcal sore throat. Lower limb erysipelas often begins near areas affected by athlete’s foot or minor trauma. 

When assessing a suspected case of erysipelas, it is essential to consider other conditions that can mimic its presentation. Differentiating between these conditions ensures accurate treatment and helps avoid unnecessary interventions. 

It is important to differentiate erysipelas from other conditions: 

• Cellulitis: Diffuse, deeper infection with ill-defined borders 

• DVT: Pain and swelling without redness or fever 

• Contact dermatitis: Itchy, not painful; usually lacks fever 

• Herpes zoster: Follows a dermatomal pattern with blisters 

• Angioedema: Sudden swelling, typically allergic, without redness 

• Necrotizing fasciitis: Severe pain, rapid spread, possible gas formation 

Autoimmune conditions like lupus may mimic erysipelas but usually present with symmetrical rashes and lack acute systemic features. 

Diagnosing erysipelas typically begins with a detailed evaluation of the patient’s symptoms and physical appearance. Because the condition has distinct features, doctors often rely on clinical clues rather than invasive tests. 

Clinical assessment remains the cornerstone of diagnosis, relying on the distinct appearance of the rash and the patient’s accompanying symptoms. However, additional tests can provide supportive information and help rule out complications or alternative diagnoses. 

Supportive investigations 

• Blood tests: Elevated white blood cell count, increased C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) 

• Blood cultures: Useful in severe or systemic cases, positive in fewer than 5% of patients 

• Microbiology: Skin cultures are typically unhelpful since the infection is non-purulent; throat swabs may aid diagnosis in facial erysipelas linked to streptococcal pharyngitis 

Imaging 

Not routinely needed unless complications are suspected. 

• Ultrasound or MRI: May be considered if abscess, necrotizing infection, or deep tissue involvement is a concern 

Treating erysipelas focuses on eliminating the infection with antibiotics and addressing any underlying conditions that may contribute to recurrence. Supportive care measures can help relieve symptoms and promote healing, especially in more severe cases. 

Antibiotic therapy 

• First-line: Oral penicillin V for mild cases; IV penicillin G for severe or hospitalized cases 

• Alternatives: Clindamycin (for penicillin-allergic patients), cephalosporins (e.g., cefazolin), macrolides (e.g., erythromycin, though resistance is increasing) 

• Duration: 5–10 days for mild to moderate infections; 10–14 days for severe or recurrent cases 

Addressing underlying causes 

• Treat fungal infections such as athlete’s foot 

• Use compression therapy after acute symptoms resolve 

If untreated, erysipelas can lead to significant complications. 

Local complications 

• Abscesses 

• Skin necrosis (rare) 

Systemic complications 

• Bacteremia 

• Sepsis 

• Rarely, septic arthritis or endocarditis 

Long-term complications 

• Recurrent episodes 

• Chronic lymphedema 

• Elephantiasis nostras verrucosa (severe lymphedema) 

If untreated, erysipelas can progress to deeper infections such as cellulitis or necrotizing fasciitis. Streptococcal toxic shock syndrome, although rare, is a life-threatening complication. 

Preventive strategies reduce the risk of both first-time and recurrent infections. 

Skin care 

• Moisturize dry skin 

• Treat wounds and fungal infections promptly 

Lymphedema management 

• Compression stockings 

• Manual lymphatic drainage 

Antibiotic prophylaxis 

• For recurrent cases (3 or more episodes/year) 

• Long-term low-dose penicillin or erythromycin 

Public health strategies focusing on hygiene, especially foot care in diabetics, can significantly reduce incidence in high-risk groups. 

With appropriate treatment, erysipelas typically resolves within one to two weeks. Early intervention is associated with excellent outcomes. However, recurrence is common if risk factors are not addressed. 

While mortality is rare, it may occur in the elderly or immunocompromised individuals with systemic involvement. Long-term monitoring may be needed in those with chronic venous or lymphatic conditions. 

Erysipelas is a common and potentially recurrent skin infection that requires prompt clinical recognition and treatment. With its distinctive presentation and rapid onset, diagnosis is often straightforward. Antibiotic therapy and management of underlying conditions are critical to reducing recurrence and complications. Preventive care, especially in high-risk individuals, plays a major role in improving outcomes and reducing healthcare burden. 

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