An infection of the upper dermis, erysipelas classically presents abruptly as a painful superficial cellulitis with associated fever, regional lymphade-nopathy, and lymphangitis. A prodrome of a flu-like illness may precede the appearance of rash by several hours to 2 days. Distinct elevated borders surround brightly erythematous plaques that have no central clearing. Usually involving the lower extremities in more than 75% to 90% of cases, the face also is reported to be involved in 2.5% to 10% of cases [17,18]. Risk factors include tinea pedis, venous insufficiency, obesity, puncture sites, pressure ulcers, and lymphedema [19]. The microbiology associated with this infection is primarily S pyogenes. Other organisms reported to be associated with erysipelas include other beta-hemolytic streptococci (ie, Group B, C, or G), S aureus, enterococci, and, rarely, Gram-negative bacilli. The diagnosis remains clinically based; about 5% of patients are bacteremic and cultures from the skin are positive in less than 50% of cases [17]. Most patients can be treated as outpatients with oral antibiotics, such as penicillin, dicloxacillin, or cephalexin. Hospitalization can be considered for more severe cases, including patients who manifest systemic signs and symptoms, such as confusion and hypotension, or who are immunocompromised. Intravenous penicillin, cefazolin, nafcillin, or oxacillin can be considered for treatment of these patients. Rest, immobilization, moist heat, and elevation of the affected area are often recommended as supportive measures. Necrosis of the skin, abscess formation, bursitis, venous thrombophlebitis, osteitis, and septic arthritis are uncommon complications [20]. Recurrences occur in up to 29% of patients and appear more likely in the setting of leg ulcers, skin trauma, and tinea pedis [19,21].

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