Evidence Based Disease Management Presentation
Diagnosis: Cellulitis / Folliculitis
ICD-10 Code(s):
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LO3 Cellulitis and acute lymphangitis
L03.0 Cellulitis of finger and toe
L03.1 Cellulitis of other parts of limb
L03.2 Cellulitis of face
L03.3 Cellulitis of trunk
L03.8 Cellulitis of other sites
L03.9 Cellulitis, unspecified
Pathophysiology:
Cellulitis is defined as bacterial skin infection. It is a breach to the affected skin such as a fissure,
cut, laceration, insect bite or puncture wound. The affected area becomes irritated, swollen and
can be painful. There might a microscopic break in the skin barrier. The affected areas can range
from face, arms, legs, etc. Individuals with DM are at risk for more sever diseases. Cellulitis
should be treated immediately to avoid further infection, which can spread to lymph nodes and
bloodstream leading to sepsis. Majority of the cellulitis cases are cuased by Streptococcus
pyogenes or by Staphylococcus aureus.
Subjective: Clinical presentation can vary per individual and type of incontinence
Skin irritated that expand
Swelling
Tenderness/ Pain
Warmth
Fever
Chills
Spots
Blisters
Skin dimpling
Skin discoloration
Objective: Varies based on area:
 Skin barrier affected with rash, redness, swelling, and/or pus
 Fever with abnormal vital signs such as high BP, HR
Diagnostic Studies:
Moderate Case
CBC
ESR and CRP
Creatinine levels
Severe Case
CBC with differential
ESR and CRP
Creatinine levels
Blood cultures
Ultrasonography
CT/MRI imaging
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Needle aspiration and biopsy
Management: Identify and treat causes
 Education:
o Wash the wound daily with soap and water.
o Apply a protective cream (Vaseline, Polysporin) for protection.
o Cover the wound with a bandage. Change bandages at least daily.
o Signs of infection: Irritation, pain and pus
o Elevation of affected body part to reduce edema
o Compression therapy
o People with Diabetes or poor circulation need additional education:
 Inspecting feet daily.
 Moisturizing skin regularly.
 Trimming fingernails and toenails carefully.
 Wear footwear and gloves suitable to activities.
 Promptly treating infections on the skin's surface
Drug Therapy:
 Antibiotic regimens are effective in more than 90% of patients
o Mild case
 dicloxacillin 500mg orally every 6 hrs
 cephalexin 500 mg orally every 6 hrs
 cefadroxil 500mg every 12 hrs or 1 g orally once daily
 If allergic to penicillin: Clindamycin (450mg every 8hrs) or macrolide
 Treatment of recurrent disease
o Daily amoxicillin (250mg BID) or erythromycin (250mg BID)
 Patients with severe cellulitis require parenteral therapy:
o Medications include:
 Cefazolin 1 or 2 g IV every 8 hrs
 Nafcillin 1 or 2 g IV every 4 hrs
 Oxacillin 1 or 2 g IV every 4 hrs
o Broad gram-positive, gram-negative, and anaerobic coverage for cases associated
with diabetic ulcers
o Coverage for MRSA, until culture & sensitivity information available:
 TMP-SMX
 Amoxicillin 875mg orally BID plus doxycycline 100mg orally BID
 For cellulitis involving wounds sustained in an aquatic environment, recommended
antibiotic as follows:
o Saltwater or brackish water: doxycycline and ceftazidime, or a fluoroquinolone
o Freshwater: a third- or fourth-generation cephalosporin (eg, ceftazidime or
cefepime) or a fluoroquinolone (eg, ciprofloxacin or levofloxacin)
 Consult an infectious disease specialist if the patient is not improving with standard
treatment.
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Guidelines/Websites:
 Medscape: https://emedicine.medscape.com/article/214222-treatment#d1
 https://www.cdc.gov/groupastrep/diseases-public/Cellulitis.html
 https://www.uptodate.com/contents/acute-cellulitis-and-erysipelas-in-adults-treatment
Referral:
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Follow Up:
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Infectious disease if case is sever
Initial f/u 2 weeks
If sever case then based on symptoms and healing of wound
References
Collazos, J., de la Fuente, B., García, A., Gómez, H., Menéndez, C., Enríquez, H., Sánchez, P.,
Alonso, M., López-Cruz, I., Martín-Regidor, M., Martínez-Alonso, A., Guerra, J., Artero,
A., Blanes, M., de la Fuente, J., & Asensi, V. (2018). Cellulitis in adult patients: A large,
multicenter, observational, prospective study of 606 episodes and analysis of the factors
related to the response to treatment. PLOS ONE, 13(9),
e0204036. https://doi.org/10.1371/journal.pone.0204036
Ortiz-Lazo, E., Arriagada-Egnen, C., Poehls, C., & Concha-Rogazy, M. (2019). An update on
the treatment and management of cellulitis. Actas Dermo-Sifiliográficas (English
Edition), 110(2), 124–130. https://doi.org/10.1016/j.adengl.2019.01.011
Santer, M., Lalonde, A., Francis, N. A., Smart, P., Hooper, J., Teasdale, E., Del Mar, C.,
Chalmers, J. R., & Thomas, K. S. (2018). Management of cellulitis: Current practice and
research questions. British Journal of General Practice, 68(677), 595–
596. https://doi.org/10.3399/bjgp18x700181
Spelman, D., & Baddour, L. M. (2022). Acute cellulitis and erysipelas in adults: Treatment (F.
D. Lowy & K. K. Hall, Eds.). UpToDate. Retrieved November 3, 2022,
from https://www.uptodate.com/contents/acute-cellulitis-and-erysipelas-in-adultstreatment#:~:text=In%20general%2C%20five%20to%20six,response%20to%20therapy
%2C%20or%20immunosuppression.
Sullivan, T., & de Barra, E. (2018). Diagnosis and management of cellulitis. Clinical
Medicine, 18(2), 160–163. https://doi.org/10.7861/clinmedicine.18-2-160
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