What is Erysipelas?

Erysipelas, also known as “red skin“, “ignis sacer“, “holy fire” or “St. Anthony’s fire” is an acute infection manifested typically with a skin rash that is usually localized on face and legs, but it can be also manifest on toes, arms and fingers.

This infection impacts upper dermis and superficial lymphatics, and it is most commonly caused by beta-hemolytic group A Streptococcus bacteria on scratched or otherwise infected areas of the body. Erysipelas is manifested intensely with erythematous, indurated plaque with a border that is sharply demarcated.

This is sometimes followed by other symptoms, including fevers, blisters and chills. Its well-defined margin can help in differential diagnosis from other skin infections. It is similar to another skin disease called cellulitis, which impacts lower layers of the skin. Both conditions are similar in appearance and are treated in the same way.

Erysipelas, also known as "red skin", "ignis sacer", "holy fire" or "St. Anthony's fire"  erysipelas leg pictures

Erysipelas pronunciation

Erysipelas is pronouncing \ˌer-ə-ˈsi-p(ə-)ləs, ˌir-\

Erysipelas epidemiology

Erysipelas is in general individual-case disease, although epidemics have been also reported. Erysipelas incidence declined during the mid-20th century, probably because of antibiotic development, decreased virulence and improved sanitation. However, according to U.S. epidemiology data, there is an increasing incidence of this condition since the late 1980s.

Erysipelas distribution from the face to the lower extremities is most likely linked to an elderly population with increased risk factors such as lymphedema. Approximately 80% of patients has their erysipelas occur on the legs rather than the face.
It has been found that erysipelas is somewhat more common in European countries where, isolated cases are still dominant, but the distribution and etiology remain similar to those in the United States.

Erysipelas affects persons of all races. It has been reported, that this condition is more common in females but occur more frequently at an earlier age in males, likely because of a higher incidence of skin injuries in younger males. Other studies showed that predisposing factors, likely than gender, account for any male/female differences in incidence.

Erysipelas infections cases have been reported in all age groups, but it has been found that infants, young children, and elderly are most commonly affected. The maximum incidence has been reported in elderly patients aged 60-80 years, especially in those who are immunocompromised or those with lymphatic drainage problems such as those with pelvic surgery, mastectomy or bypass grafting.

Erysipelas signs and symptoms

Infected patients usually develop symptoms such as high fevers, chills, headaches, shaking, fatigue, vomiting and general illness within 48 hours of infection. Erythematous lesion of skin enlarges fast and has a sharply demarcated, raised edge. Skin is red, warm, swollen and painful, very similar in consistency to an orange peel. Severe infections may result in vesicles, blisters, and petechiae and possible skin necrosis.

In addition, lymph nodes may be swollen with possibility of lymphedema occurring. Rarely, a red streak extending to the lymph node can be observed. Fat tissue and facial areas of the skin, specifically around the eyes, ears, and cheeks, are most vulnerable. Repeated extremities infection can lead to chronic swelling (lymphangitis).

Is erysipelas painful?

Yes it is, since the lession may be red, warm and painful. NSAID’s use is recommended for pain treatment. Severe pain, however requires narcotic analgesic treatment.

What is erysipelas caused by?

Erysipelas begins with a skin disruption of the barrier, thus allowing the infective agent to enter. This happens most commonly after abrasion, herpes simplex virus or interdigital tinea pedis infections, different traumas, but it may also be caused by insect bites, puncture wounds, ulcers, post-vaccination, or neonate’s exposure of umbilical stump.

The nasopharynx in bacterial carriers is usual source of inoculation. But, primary inoculation may also occur. Once the skin is inoculated, infection will rapidly spread and may show extensive lymphatic involvement. Lymph node enlargement and tenderness may also occur.

The most common cause of erysipelas is GABHS (Group A beta-hemolytic streptococcal infections) by Streptococci Groups B, C, and G. Rarely, erysipelas is caused by Staphylococcus aureus.

Other etiologic agents including include Streptococcus pneumoniae, Klebsiella pneumoniae, Yersinia enterocolitica and Haemophilus influenzae should be also considered in immunocompromised patients or in those with no improvement after standard antibiotic therapy.

What are the risk factors for erysipelas?

Predisposing factors in erysipelas include the following:

  • Lymphatic obstruction or edema
  • Saphenous vein grafting in lower extremities
  • Status postradical mastectomy
  • Immunocompromise: Including patients who are diabetic or alcoholic or who have human immunodeficiency virus (HIV)
  • Arteriovenous insufficiency
  • Paretic limbs
  • Nephrotic syndrome
  • Vagrant lifestyle

Laboratory diagnostic of erysipelas

Mentioned clinical findings are most important for erysipelas diagnostic. However, certain diagnostic tests should be also peformed in order to differentiate erysipelas from other skin disorders. A complete blood count is suitable and might demonstrate leukocytosis and a left shift, but may also be normal, especially in patients who are immunocompromised.

Needle aspiration may be performed, and the aspirate cultured. Nasopharynx swab culture may aid in isolating an etiologic pathogen. Blood cultures are usually reserved for when bacteremia is suspected because they are positive in only 5%. Magnetic resonance imaging (MRI) and Computational tomography (CT) may be useful for detecting deeper infection.

Histopathology of Erysipelas

Histological analysis indicates a mixed interstitial infiltrate predominately of neutrophils within a clear edematous dermis. Capillaries and lymphatics are dilated. Infiltrate may cover the whole dermis and sometimes extend into subcutaneous fat. Giemsa or Gram stain can show streptococci in the tissue and within the lymphatics.

Recurrent erysipelas is manifested with fibrotic thickening of lymphatic vessel walls, occasionally with luminal occlusion. Dilated capillaries and lymph vessels can be also present.

Differential diagnosis of Erysipelas

The differential diagnosis can be various. It can include cellulitis, insect bites and stings, ecthyma gangrenosum, allergic contact dermatitis, urticaria, herpes simplex, erysipeloid, necrotizing fasciitis, and carcinoma erysipeloides. Arthropod bites and stings may be the cause of significant lymphedema and erythema around the area of the bite/sting.

But, differently from erysipelas, the area is pruritic and is less much likely to be painful. The skin manifestations also progress in a matter of hours rather than days. Cellulitis is however similar to erysipelas but the erythema is less well-defined and doesn’t have the sharply raised borders of erysipelas. Cellulitis is a deeper infection that involves the skin and soft tissues, and often fascia, muscles, and tendons.

Ecthyma gangrenosum is usually characterized with angioinvasion and vesiculobullous eruption is typically caused by Pseudomonas aeruginosa infection. In comparison with Stretococci infection, P. aeruginosa invades cutaneous blood vessels and perivascular connective tissue, leading to coagulative necrosis.

Ecthyma gangrenosum usually begins as erythematous macules, becomng pustular and ultimately developing into erythematous skin that, within hours to days, becomes dusky with bullae formation. It is then quickly followed by gangrene and necrosis, with crepitus if due to a gas-producing infective agents. Infection spreads rapidly, extending vertically and horizontally along the deep fascial plane.

Common predisposing factors for necrotizing fasciitis are soft tissue injury and diabetes mellitus. Without prompt treatment, patients can develop systemic toxicity, fever, organ failure and shock, often resulting in death. CT or MR imaging may help to delineate the extent of infection, and biopsy with tissue culture may help direct antibiotic therapy.

Unlike erysipelas, necrotizing fasciitis needs a surgical emergency requiring prompt surgical debridement, fasciotomy, and, occasionally, amputation of the affected extremity. Treatment with intravenous antibiotics is mandatory. Even with treatment, mortality can approach 70%.

Is Erysipelas contagious? How long does erysipelas last?

Erysipelas is a highly contagious condition bencause the fact that it is caused by bacterial infection. It can be transmitted by physical contact or by touching the saliva, sputum or blood of an infected person.

Transmission routes are: air, cough, surfaces, fecal-oral route, blood, needles, blood transfusions, sexual contact, mother to fetus, etc. Family members of erysipelas sufferers should take proper care before drying and washing the lesions arising due to this disease. This disease may also infect healthy people administering care to the sufferer.

While some patients may be healed completely in 1-2 weeks, in some cases the skin changes may persist indefinitely due to damage to the lymphatic ducts that make such patients prone to recurrences.

Prognosis and complications of erysipelas

Erysipelas prognosis is excellent. If complications occur they are usually not life threatening, and most cases are resolved after antibiotic therapy. This condition may also be resolved spontaneously, without treatment.

Complications of erysipelas may include the following:

  • Gangrene/amputation
  • Chronic edema
  • Scarring
  • Bacteremia sepsis
  • Scarlet fever
  • Pneumonia
  • Abscess
  • Embolism
  • Meningitis
  • Death

The most common complications of erysipelas include abscess, thrombophlebitis and gangrene. Less common complications (< 1%) are acute glomerulonephritis, septicemia, endocarditis and streptococcal toxic shock syndrome. Rare osteoarticular complications may include joints contiguous with the erysipelas plaques and may include osteitis, bursitis, arthritis, and tendinitis.

Recurrence has been reported in about 20% of patients with predispositions, leading to disfiguring and disabling sequelae, such as elephantiasis nostras verrucosa. This chronic edematous condition is caused by lymphatic destruction from repeated infection.

Although erysipelas can be easily and successfully managed with oral antibiotics, it can be fatal when it is associated with bacteremia in very young, elderly, or immunocompromised patients. Mortality rate of less than 1% in treated cases.

Erysipelas treatment

While most cases of erysipelas can be easily resolved, urgent treatment is however very important because of potentially rapid progression. Aside from administration of antibiotics, primary care also includes the following:

  • Symptomatic treatment of aches and fever
  • Cold compresses
  • Hydration (oral intake if possible)
  • Elevation and rest of the affected limb
  • Saline wet dressings: Should be applied on ulcerated and necrotic lesions and changed every 2-12 hours, depending on the severity of the infection

Surgical care is necessary only in severe infections with necrosis or gangrene.

Inpatient care. Hospitalization and close monitoring with intravenous antibiotics therapy is recommended in severe cases, immunocompromised patients, infants and elderly persons. Patient monitoring is also recommended for patients with significant comorbidities and in those who are unlikely to complete the course of treatment as a result of psychosocial reasons.

Pharmacologic Treatment

Streptococci is in most cases cause of erysipelas. therefore, penicillin is the first-line therapy. Orally or intramuscularly administrated penicillin is efficient in most cases of classic erysipelas and should be given for at least 5 days, but if the infection is not healed, treatment should be extended.

First-generation cephalosporins may be also used if the patients are allergic to penicillins. However, cephalosporins may cross-react with penicillins and should be used carefully in patients with a history of severe penicillin allergy, such as anaphylaxis.
Clindamycin aslo remains a therapeutic option, although there are well documented clindamycin-resistant group B streptococcal isolates. Erythromycin-resistant group B streptococcal isolates are common. 
So, early or mild erysipelas episodes can be managed effectively with 250 to 500 mg oral penicillin V – phenoxoymethyl penicillin. In penicillin-sensitive patients, 250 to 500 mg erythromycin oral doses are good alternative. Severe or advanced cases need to be hospitalized and treated with 600,000 to 2 000 000 units IV aqueous penicillin on every 6 hours.
When therapy response is slow or when staphylococcal organisms are suspected, treatment option is also 500 to 1000 mg oral oxacillin or in the case of more severe manifestations.
Typical erysipelas infections usually don’t need a coverage for Staphylococcus aureus but it should be always considered in patients who do not have improvement after penicillin therapy or in those who have atypical forms including bullous erysipelas.
There is an opinion that facial erysipelas should be treated with a penicillinase-resistant antibiotic, such as dicloxacillin or nafcillin in order to cover possible S. aureus infection, but there is a need for supporting evidence.

Two drugs, pristinamycin and roxithromycin have been showed to be extremely effective. Several studies have showed greater efficacy and less adverse effects with these drugs compared with penicillin. However FDA has not approved these drugs for use in United States but they are in use in Europe.

The FDA approved 3 antibiotics: dalbavancin (Dalvance), oritavancin (Orbactiv) and tedizolid (Sivextro) for the management of acute bacterial skin and skin structure infections. These agents are active against Staphylococcus aureus (including methicillin-susceptible and methicillin-resistant S aureus [MSSA, MRSA]), Streptococcus agalactiae, Streptococcus pyogenes and Streptococcus anginosus group including Streptococcus anginosus, Streptococcus intermedius, and Streptococcus constellatus, among others.

Most patients respond preety well to conventional antibiotic therapy. However, if it is the case of atypical infections that are unresponsive to first- and second-line antibiotics, consultation with an infectious disease specialist is very advisable where the diagnosis is in doubt.

Topical treatment of erysipelas

Topical medications are indicated when surface skin changes occur that penetrate the integrity of the overlying epidermis. This breakable tissue should be elevated in order to reduce edema and promote the delivery of the systemic antimicrobials.

Additionally, a foot cradle prevents further trauma, and if the surface is exudative or moist, evaporative soaks of 0.25% acetic acid solution cleanse, dry, and prevents secondary infection. Applications of an ointment containing polymyxin B sulfate and bacitracin is recommended, once the exudative phase is past.

Long-term treatment of erysipelas

Patients with recurrent infections should be educated about local antisepsis actions and general wound care. Predisposing lower extremity skin lesions such as: tinea pedis, stasis ulcers, toe web intertrigo, asteatotic dermatitis need to be treated aggressively in order to prevent superinfection.

Compression stockings use should be encouraged for as long as 1 month in previously healthy patients and long-term in patients with lower extremity edema. Long-term management of lymphedema is essential. In such cases, long-term prophylactic therapy with antibiotics is generally accepted.

One regimen is benzathine penicillin G at 2.4 mU intramuscularly every 2-4 weeks for up to 2 years. Oral penicillin or erythromycin twice daily for 4-52 weeks is an alternate regimen. 

Drugs indicated for Erysipelas


Penicillin G procaine (Wycillin) and penicillin VK (PenVeeK) are currently recommended as first-line agents for the treatment of moderately severe infections of skin and skin structure. In adults, administer penicillin G procaine by deep intramuscular injection only into upper, outer quadrant of buttock. In infants and small children, the midlateral aspect of the thigh may be a better site for administration.

Dicloxacillin, used in the treatment of infections caused by penicillinase-producing staphylococci, is a penicillinase-resistant penicillin that will cover possible S aureus.

Nafcillin is the initial therapy for suspected penicillin G ̶ resistant streptococcal or staphylococcal infections. Use parenteral therapy initially in severe infections, and change to oral therapy as the condition warrants. Because nafcillin may cause thrombophlebitis at the injection site, particularly in elderly patients, administer parenterally only for a short term (1-2 d); change to oral administration as clinically indicated.

Cephalexin (Keflex) is a first-generation cephalosporin that inhibits bacterial growth by inhibiting bacterial cell wall synthesis. This agent is bactericidal and is effective against rapidly growing organisms forming cell walls. Cephalexin is an acceptable alternative to penicillin and may be useful in patients with minor penicillin allergies.

Erythromycin (Ery-Tab, PCE, Erythrocin) is a macrolide used for penicillin-allergic individuals. It inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer ribonucleic acid (t-RNA) from ribosomes, causing RNA-dependent protein synthesis to arrest. Erythromycin is administered for the treatment of staphylococcal and streptococcal infections. In children, age, weight, and severity of infection determine proper dosage. When twice-daily dosing is desired, half of the total daily dose may be taken every 12 hours. For more severe infections, double the dose.

Azithromycin (Zithromax, Zmax) acts by binding to the 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected. Azithromycin concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques.

In vivo studies suggest that its concentration in phagocytes may contribute to drug distribution to inflamed tissues. Azithromycin treats mild-to-moderate microbial infections. Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. It has a long tissue half-life, which allows for once-daily dosing for skin and soft-tissue infections.

Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal) is a lincosamide for the treatment of serious skin and soft-tissue staphylococcal infections. It is also effective against aerobic and anaerobic streptococci (except enterococci).

Clindamycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Clostridium difficile-associated diarrhea is a potential adverse effect.


Acetaminophen (Tylenol, Aspirin Free Anacin, APAP 500, Acephen, FeverAll) is the drug of choice (DOC) for treating pain in patients with documented hypersensitivity to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), who are diagnosed with upper gastrointestinal disease, or who take oral anticoagulants.

Codeine/acetaminophen is used for the treatment of mild to moderate pain.

Hydrocodone bitartarate and acetaminophen (Vicodin ES, Lortab, Zydone, Norco). This combination is used for the relief of moderate to severe pain.

Oxycodone bitartarate and acetaminophen (Percocet, Endocet, Roxicet, Magnacet). The combination of oxycodone and acetaminophen is used for the relief of moderate to severe pain. It is the DOC for aspirin-hypersensitive patients.

Aspirin (Ascriptin Regular Strength, Bayer Aspirin, Aspirtab, Ecotrin) blocks prostaglandin synthetase action, which in turn inhibits prostaglandin synthesis and prevents the formation of platelet-aggregating thromboxane A2; it acts on the hypothalamic heat-regulating center to reduce fever.

Ibuprofen (Addaprin, Advil, Motrin, Caldolor, Dyspel) is usually the DOC for treating mild to moderate pain, if no contraindications exist. It is one of the few NSAIDs indicated for fever reduction.

Naproxen (Naprosyn, Aleve, Naprelan, Anaprox) is used for the relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing COX activity, which results in decreased prostaglandin synthesis.

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient’s response.

Erysipelas vs Cellulitis

In comparison to cellulitis, erysipelas lesion is raised with a clear line at the edge of the infected lesion. When face is affected by erysipelas, the swollen area is usually on the nose and both cheeks. On the other hand cellulitis is most commonly linked with lymphangitis, as an inflammation of one or more lymphatic vessels which usually occur on one side of the body.

Common symptoms of erysipelas and cellulitis can include:

  • A swollen, red, and painful area of skin with a raised edge (erysipelas)
  • A red area of skin that tends to expand (cellulitis)
  • General tissue swelling
  • Swollen glands
  • Tenderness and pain
  • Blisters on the affected area
  • Feels warm to the touch
  • Red spots
  • Fever
  • Skin dimpling
  • Chills

At most time, cellulitis and erysipelas share the same complications. They can spread throughout the body and enter the bloodstream and lymph nodes. Potential complications can include:

  • A blood infection
  • A bone infection
  • Tissue death, or gangrene
  • An inflammation of lymph vessels
  • Abscess formation
  • A blood clot due to inflammation (Thrombophlebitis)
  • An inflammation or an infection of the lymphatic channels (Lymphangitis)
  • Chronic leg edema which is a late complication that may predispose to further episodes of infection

Less common, but more serious complications occurring in less than 1 % may include:

  • An inflammation of bone or bone marrow (Osteomyelitis)
  • A rapid destruction of the overlying tissues (Necrotising fasciitis)
  • An inflammatory disease of both kidneys (Acute glomerulonephritis)
  • Blood poisoning (Septicaemia)
  • An inflammation affecting the heart (Endocarditis)
  • Streptococcal toxic shock syndrome
  • Compartment syndrome

Cellulitis treatment is similar to erysipelas treatment. Antibiotics are also used to treat the infection, and medication is prescribed for pain and inflammation. But in comparison to erysipelas, cellulitis treatments are usually prolonged, depending on the severity of the condition.

Erysipelas prevention

Take the following precautions to help lower your risk of erysipelas:

  • Clean any cuts or sores in your skin immediately, and apply an antibiotic cream or ointment.
  • Until the wound begins healing, keep it covered with a bandage, and change it regularly.
  • Avoid scratching and damaging your skin.
  • Use skin cream moisturizers to help prevent dry and cracked skin.
  • Treat any skin diseases such as eczema or psoriasis as needed.
  • Treat athlete’s foot with an anti-fungal medication as soon as it presents.
  • Wear protective gear when needed to avoid any injury to the skin.
  • Make sure you follow up with any appointments you may have with your health care provider.

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