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Cellulitis

Cellulitis is a common acute bacterial skin infection that affects the deeper layers of the skin (dermis) and underlying subcutaneous tissues, typically presenting as a rapidly spreading area of redness, swelling, warmth, and tenderness.^[1] It is most often caused by bacteria such as group A Streptococcus (Streptococcus pyogenes) or Staphylococcus aureus entering through breaks in the skin, including cuts, insect bites, surgical wounds, or conditions like athlete's foot.^[2] While it can occur anywhere on the body, it frequently affects the lower legs, and prompt antibiotic treatment is essential to prevent complications like abscess formation or bloodstream infection.^[3] The infection triggers an inflammatory response involving cytokines and neutrophils, leading to the characteristic signs of local inflammation without initial abscess or purulent drainage.^[3] Common symptoms include pain or tenderness at the site, fever, chills, and swollen lymph nodes, with the affected skin often appearing shiny or stretched; in severe cases, blisters, fever above 100.4°F (38°C), or systemic symptoms may develop.^[1] Risk factors for developing cellulitis encompass skin injuries, chronic conditions such as diabetes or lymphedema, weakened immune systems (e.g., from HIV or chemotherapy), obesity, and prior episodes of the infection, which increase recurrence rates to 8-20% annually.^[3] Epidemiologically, it impacts over 14 million people yearly in the United States, with an incidence of about 50 cases per 1,000 patient-years, affecting adults of all ages but more commonly middle-aged and older individuals.^[3] Diagnosis is primarily clinical, based on physical examination of the affected area, though blood tests or imaging may be used to rule out deeper infections or complications in hospitalized patients.^[4] Treatment typically involves oral antibiotics such as cephalexin for 5-10 days in mild cases, with intravenous options like vancomycin for severe or MRSA-suspected infections; symptoms often improve within 48 hours of starting therapy.^[3] Supportive measures include elevating the affected limb, applying cool compresses, and using over-the-counter pain relievers, while hospitalization is required for extensive involvement or systemic signs.^[4] Prevention focuses on protecting the skin from injury, promptly treating wounds, and managing underlying conditions like edema to reduce recurrence.^[2] With appropriate care, the prognosis is excellent, though untreated cases can progress to serious issues like bacteremia, sepsis, or necrotizing fasciitis.^[1]

Clinical Presentation

Signs and Symptoms

Cellulitis typically presents with localized signs of infection at the affected site, including erythema, edema, warmth, and tenderness or pain. The skin appears red and inflamed, often with poorly demarcated or ill-defined borders that expand over time, and the area feels warm to the touch due to increased blood flow and inflammatory response. In lighter skin tones, the affected area appears red; in darker skin tones, it may appear purple, brown, or gray.^[1]^[2]^[5]^[6]^[3] Systemic symptoms frequently accompany the local manifestations, such as fever, chills, fatigue, and malaise, indicating the body's broader immune response to the bacterial invasion. Patients may also experience swollen lymph nodes or glands near the infection site as the lymphatic system reacts.^[1]^[7]^[3] The infection often progresses rapidly, spreading from the initial site within hours to days, potentially leading to lymphangitis characterized by red streaks extending toward the lymph nodes, signaling lymphatic involvement. In severe cases, blistering may occur, with fluid-filled bullae forming on the skin surface, and ulceration can develop if the infection erodes deeper tissues.^[8]^[9]^[3] Lower extremity involvement is the most common presentation, accounting for a significant proportion of cases, where swelling and pain can restrict movement and weight-bearing. Facial cellulitis may cause pronounced swelling around the cheeks or jaw, while orbital cellulitis involves eyelid swelling, proptosis, and eye movement pain, potentially impairing vision. Perineal or perianal cellulitis often includes itching alongside redness and pain during bowel movements. Patients commonly report throbbing pain that limits joint mobility, particularly in limb infections, and occasional itching in specific locales like the perianal area.^[3]^[10]^[11]^[12]

Complications

Cellulitis, if not promptly treated, can progress to serious local and systemic complications due to bacterial spread within tissues or into the bloodstream. Local complications arise from extension of the infection into deeper structures, while systemic ones involve dissemination that can affect distant organs. Factors such as delayed initiation of antibiotics or presence of underlying conditions like diabetes or immunosuppression exacerbate the risk and severity of these outcomes.^[3] Local complications include abscess formation, where pus accumulates in the infected area due to contained bacterial proliferation, often requiring incision and drainage. The infection may also spread to deeper layers, leading to necrotizing fasciitis, a rapidly progressive and life-threatening condition characterized by tissue necrosis along fascial planes that necessitates emergent surgical intervention. Additionally, contiguous spread to adjacent bone can result in osteomyelitis, particularly in cases involving the lower extremities or in patients with vascular compromise.^[3]^[1]^[2] Systemic complications occur when bacteria enter the circulation, potentially causing bacteremia, which can further lead to sepsis—a dysregulated immune response that impairs organ function and carries high mortality if untreated. From bacteremia, the infection may seed distant sites, resulting in endocarditis, an inflammation of the heart's inner lining and valves, or suppurative arthritis in joints. In rare instances, streptococcal strains associated with cellulitis can trigger post-infectious glomerulonephritis, an immune-mediated kidney inflammation.^[3]^[1]^[2] Recurrent cellulitis affects up to 49% of patients over time, with an annual recurrence rate of 8-20%, often linked to persistent lymphatic damage from prior episodes. This can culminate in chronic lymphedema, a progressive swelling resembling elephantiasis due to impaired lymphatic drainage, which further predisposes to repeated infections in the affected limb.^[3]^[13] Rare but severe outcomes encompass toxic shock syndrome, a toxin-mediated systemic illness with multi-organ failure, and gangrene, where tissue death from vascular occlusion or unchecked infection may necessitate amputation, especially in immunocompromised individuals. Complications like these are more likely when initial symptoms such as escalating pain or systemic fever signal progression but are overlooked. Delayed treatment heightens the likelihood of deep tissue involvement or dissemination, while comorbidities including obesity, venous insufficiency, or prior lymphedema amplify complication rates and worsen prognosis.^[1]^[5]^[3]

Etiology and Risk Factors

Causes

Cellulitis is primarily caused by bacterial infection, with the most common pathogens being beta-hemolytic streptococci, particularly group A Streptococcus (Streptococcus pyogenes), and Staphylococcus aureus, including methicillin-sensitive strains (MSSA).^[3] These bacteria typically reside on the skin surface or in the nasal passages and gain access to deeper tissues through breaches in the skin barrier, such as cuts, abrasions, surgical wounds, or insect bites, triggering an acute inflammatory response in the dermis and subcutaneous layers.^[14] The infection leads to the release of cytokines and recruitment of neutrophils, resulting in the characteristic signs of localized erythema, warmth, swelling, and pain.^[3] Less common causative agents include Haemophilus influenzae type b in unvaccinated children, particularly causing facial or periorbital cellulitis, as well as gram-negative rods like Pseudomonas aeruginosa in immunocompromised individuals or those with diabetic foot infections, and anaerobes such as those from the Bacteroides or Clostridium genera in cases involving contaminated wounds or poor perfusion.^[15]^[3] In specific scenarios, such as animal bites, pathogens like Pasteurella multocida may be implicated, while Vibrio vulnificus can cause severe cellulitis following exposure to contaminated seawater.^[3] Etiologically, cellulitis can be classified into subtypes based on the depth and nature of infection; erysipelas represents a superficial form primarily due to streptococcal invasion of the upper dermis and lymphatics, often presenting with well-demarcated borders, whereas deeper cellulitis involves subcutaneous fat.^[16] Non-purulent cellulitis is more commonly associated with streptococci, while purulent forms suggest staphylococcal involvement, including abscess formation.^[14] Significant prevalence of methicillin-resistant Staphylococcus aureus (MRSA) as a cause of cellulitis, particularly in community settings and among individuals with prior antibiotic exposure or colonization, which complicates treatment due to its resistance profile.^[3] Additionally, biofilm formation by pathogens like S. aureus in chronic wounds contributes to persistent or recurrent cellulitis by shielding bacteria from host defenses and antibiotics, exacerbating infection in compromised tissues.^[13]

Risk Factors

Cellulitis risk is heightened by disruptions to the skin barrier, such as chronic wounds, ulcers, surgical sites, and lymphedema, which provide entry points for infection.^[3]^[17] For instance, individuals with lymphedema experience chronic swelling that impairs lymphatic drainage and skin integrity, increasing susceptibility in affected limbs.^[2] Similarly, non-healing ulcers from conditions like venous insufficiency or trauma create persistent breaches in the dermal barrier.^[5] Systemic conditions further elevate risk by compromising immune function or circulation. Diabetes mellitus impairs wound healing and neutrophil function, making infections more likely in the lower extremities.^[1] Obesity contributes through reduced mobility, skin folds that trap moisture, and associated inflammation, with obese individuals having approximately a 2- to 3-fold higher risk based on recent meta-analyses (as of 2024).^[18] Immunosuppression from HIV, chemotherapy, or corticosteroid use weakens host defenses, while peripheral vascular disease limits blood flow to deliver immune cells to potential infection sites.^[3] Intravenous drug use introduces contaminants directly into tissues, often leading to recurrent episodes at injection sites.^[5] Demographic factors include advanced age and a history of prior cellulitis. Elderly individuals face higher risk due to thinned skin, reduced mobility, and comorbidities, with incidence rates rising significantly after age 65.^[3] Young children may be vulnerable from minor skin breaks during play, though adults predominate overall. A previous episode of cellulitis increases the likelihood of recurrence, often due to underlying unresolved predispositions like edema.^[1] Environmental exposures, such as occupational contact with soil or water, can predispose certain groups. Farmers and agricultural workers risk abrasions from soil-laden tools or barefoot fieldwork in rural areas, facilitating bacterial ingress from environmental sources.^[19] Aquatic exposures, including handling fish tanks or marine activities, increase chances through cuts encountering contaminated water, as seen in higher rates among fishermen.^[3] Warmer, humid climates may exacerbate this by promoting bacterial proliferation on damaged skin.^[20] Behavioral risks encompass poor hygiene and practices that damage the skin. Inadequate cleaning of wounds or interdigital areas, such as between toes in cases of athlete's foot, allows moisture and bacteria to accumulate.^[2] Walking barefoot in endemic or contaminated areas heightens injury risk, particularly in tropical or rural settings where soil pathogens abound.^[21] These factors collectively impair the skin's protective role, enabling opportunistic bacteria to invade deeper tissues.^[17]

Diagnosis

Clinical Assessment

The clinical assessment of suspected cellulitis begins with a detailed history to identify potential risk factors and the infection's trajectory. Clinicians inquire about the onset and progression of skin changes, such as the timing of initial redness or swelling, and any history of trauma, including cuts, abrasions, insect or animal bites, or intravenous drug use, which may serve as portals of entry for bacteria.^[3] Systemic symptoms like fever, chills, malaise, or fatigue are elicited, alongside relevant comorbidities such as diabetes mellitus, peripheral vascular disease, lymphedema, venous insufficiency, or immunosuppression, which predispose patients to recurrent or severe infections.^[22] Physical examination focuses on the affected area to characterize the infection and monitor its extent. The skin lesion typically presents with ill-defined borders of erythema, distinguishing it from the raised, sharply demarcated edges seen in erysipelas, accompanied by warmth, edema, and tenderness; a diagnosis often requires at least two of these cardinal signs.^[23] The size of the involved area is measured and marked with a skin-safe pen to track progression, while regional lymph nodes are palpated for tenderness or enlargement indicating lymphatic spread.^[3] Vital signs are evaluated for systemic involvement, including temperature exceeding 38°C or heart rate greater than 90 beats per minute, which suggest more widespread infection.^[3] Severity is classified to guide management, typically as mild, moderate, or severe based on clinical features and patient factors. Mild cases involve localized infection without systemic signs, suitable for outpatient oral antibiotics; moderate severity includes systemic symptoms like fever or leukocytosis, often requiring intravenous antibiotics; severe presentations feature systemic inflammatory response syndrome (SIRS) criteria, such as high fever, tachycardia, rapid lesion spread, or immunocompromise, necessitating hospitalization.^[24] Hospitalization criteria include failure of outpatient therapy, hemodynamic instability, or signs of deeper extension like bullae formation.^[24] Red flags warranting urgent referral include facial or periorbital involvement due to the risk of rapid intracranial spread, and indicators of deeper infection such as pain disproportionate to visible signs, crepitus, or necrotic changes suggesting necrotizing fasciitis.^[25] Systemic toxicity, evidenced by hypotension, altered mental status, or mottled skin, also demands immediate specialist evaluation to prevent sepsis.^[22] Clinical scoring systems aid in quantifying severity and predicting outcomes during assessment. The Standardized Early Warning Score (SEWS), derived from vital signs like respiratory rate, heart rate, temperature, and mental status, identifies high-risk patients with a score of 4 or higher, prompting escalation of care.^[22] Similarly, modified early warning scores (MEWS) assess systemic involvement by aggregating physiological parameters, with elevated scores indicating the need for intensive monitoring or intervention in cellulitis cases.^[22]

Differential Diagnosis

Cellulitis is an acute bacterial infection of the skin and subcutaneous tissues characterized by erythema, warmth, swelling, and tenderness, but its presentation can overlap with several other conditions, necessitating a thorough clinical evaluation to avoid misdiagnosis. Accurate differentiation relies on history, physical examination findings, and recognition of distinguishing features such as the absence of systemic symptoms, specific patterns of involvement, or response to non-antimicrobial interventions.^[3]^[26] Common non-infectious mimics include deep vein thrombosis (DVT), which typically presents with unilateral leg swelling, pain, and warmth but lacks fever or leukocytosis and often improves with leg elevation.^[26]^[27] Contact dermatitis manifests as pruritic, erythematous patches with possible vesicles following allergen exposure, without systemic signs like fever, and may show peripheral eosinophilia in allergic cases.^[26]^[3] Gout causes acute, intense joint-specific pain and swelling, often in the first metatarsophalangeal joint, without the diffuse skin involvement seen in cellulitis.^[26] Lipodermatosclerosis, associated with chronic venous insufficiency, features indurated, erythematous, and painful lower leg skin changes that are often bilateral and chronic, contrasting with the acute, unilateral nature of cellulitis.^[28] Bilateral lower extremity edema in heart failure presents symmetrically with pitting edema and minimal erythema, lacking the localized warmth and tenderness of cellulitis.^[3] Infectious alternatives that mimic cellulitis include abscess, which is distinguished by fluctuance and localized collection of pus beneath the skin.^[29] Necrotizing fasciitis involves rapid progression with severe disproportionate pain, crepitus, and bullae formation, indicating deeper tissue involvement and requiring urgent surgical intervention.^[3] Herpes zoster (shingles) can imitate cellulitis with unilateral erythema and pain but is characterized by a vesicular rash in a dermatomal distribution, often preceded by prodromal symptoms.^[29]^[30] Special considerations apply in periorbital infections, where periorbital (preseptal) cellulitis causes eyelid erythema and swelling without deeper involvement, while orbital cellulitis includes proptosis, ophthalmoplegia, and vision changes due to postseptal extension.^[31]

Diagnostic Tests

Laboratory tests play a supportive role in diagnosing cellulitis by assessing systemic inflammation, though they are not specific to the condition. Elevated white blood cell (WBC) counts, C-reactive protein (CRP) levels, and erythrocyte sedimentation rates (ESR) are commonly observed in patients with bacterial infections like cellulitis, indicating an inflammatory response. For instance, in hospitalized children with skin and soft tissue infections, CRP levels ≥2 mg/dL and ESR ≥30 mm/hr were significantly associated with deeper infections requiring more aggressive management. These markers help gauge severity and monitor response to treatment but do not confirm the diagnosis on their own.^[32]^[33] Microbiological investigations aim to identify the causative pathogen but often have limited yield. Wound or tissue cultures from purulent sites are recommended when pus is present, though they are negative in up to 70% of cases, with the most frequent isolates being Staphylococcus aureus, group A streptococci, and group G streptococci. Blood cultures are advised in cases of systemic involvement, such as high fever or sepsis, but positivity rates are low, typically under 10%, and even lower (around 7%) in uncomplicated skin infections, often due to prior antibiotic use. Due to these limitations, empiric antibiotic therapy is standard without awaiting culture results in most non-severe cases.^[22]^[34] Imaging modalities are reserved for cases where complications like abscesses or deeper involvement are suspected, as uncomplicated cellulitis is primarily a clinical diagnosis. Ultrasound is a valuable, non-invasive tool for detecting subcutaneous abscesses in skin and soft tissue infections, offering high sensitivity for superficial collections. For suspected deep-seated infections, such as osteomyelitis or necrotizing fasciitis, magnetic resonance imaging (MRI) provides the most comprehensive assessment of musculoskeletal involvement, while computed tomography (CT) is useful for identifying gas in tissues or guiding surgical intervention. These are not routine due to cost and availability but are indicated when clinical findings suggest extension beyond superficial layers.^[35]^[36]^[3] Diagnostic tests for cellulitis have inherent limitations that underscore the reliance on clinical judgment. Cultures from blood or wounds frequently yield negative results, leading to empiric treatment rather than pathogen-directed therapy, and unnecessary biopsies or invasive procedures should be avoided in straightforward cases to minimize patient risk. Advanced techniques like polymerase chain reaction (PCR) for rapid pathogen identification show promise in research settings but offer no clear advantage over traditional cultures in routine clinical practice, with comparable or lower sensitivity for detecting organisms in cellulitis lesions.^[22]^[37]^[3]

Management

Treatment Approaches

The primary treatment for cellulitis involves empirical antibiotic therapy targeted at the most likely pathogens, which are typically beta-hemolytic streptococci for non-purulent cases and Staphylococcus aureus (including methicillin-resistant strains) for purulent cases. Emerging trends show increasing resistance to clindamycin among group A Streptococcus isolates (up to 33% in some regions as of 2024), so local susceptibility patterns should be considered when selecting empirical agents.^[38]^[39] For mild non-purulent cellulitis in immunocompetent adults without systemic signs, oral antibiotics such as cephalexin (500 mg four times daily) or dicloxacillin (500 mg four times daily) are recommended to cover streptococci and methicillin-sensitive S. aureus (MSSA). If methicillin-resistant S. aureus (MRSA) is suspected based on local prevalence or risk factors like recent hospitalization, options include clindamycin (300-450 mg three times daily) or trimethoprim-sulfamethoxazole (TMP-SMX; 1-2 double-strength tablets twice daily), often combined with a beta-lactam for broader streptococcal coverage.^[24]^[40] For purulent cellulitis, which often involves an associated abscess, incision and drainage is the cornerstone of management, with antibiotics added if there are systemic symptoms, extensive cellulitis, or host factors increasing complication risk; empirical coverage should include MRSA with agents like TMP-SMX or doxycycline orally for mild cases. In severe cases requiring hospitalization, intravenous (IV) antibiotics are initiated, such as vancomycin (15-20 mg/kg every 8-12 hours, adjusted for renal function) plus piperacillin-tazobactam (3.375-4.5 g every 6 hours) for broad-spectrum coverage against gram-positive, gram-negative, and anaerobic pathogens in patients with comorbidities or rapid progression. For group A streptococcal cellulitis specifically, IV options include cefazolin (2 g every 8 hours) or ceftriaxone (1-2 g daily), with a preference for shorter courses in uncomplicated presentations. Therapy duration is typically 5 days for uncomplicated cellulitis, extending to 10 days if clinical improvement is slow, with de-escalation to oral agents once the patient stabilizes.^[24]^[40]^[41]^[42] Supportive measures are integral to treatment and include elevation of the affected limb to reduce edema, analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen for pain and inflammation, and warm compresses to promote comfort, though these do not replace antibiotics. In cases with underlying causes such as lymphedema or tinea pedis, addressing these factors aids resolution but guides antibiotic selection only minimally. Outpatient management is appropriate for most mild cases in reliable patients without comorbidities, while hospitalization is indicated for severe systemic inflammatory response syndrome (e.g., fever >38°C, tachycardia >90 bpm), immunocompromise, facial or periorbital involvement, or failure of oral therapy within 48-72 hours.^[24]^[41]^[40] Special considerations apply to orbital cellulitis, a sight-threatening complication requiring immediate IV antibiotics such as ceftriaxone (2 g every 12 hours) plus vancomycin, along with urgent ophthalmology consultation and imaging to assess for subperiosteal abscess drainage. In pediatric or diabetic patients, dosing adjustments and broader empirical coverage may be needed, but core principles remain antibiotic-focused with close monitoring for response.^[41]^[40]

Prevention Strategies

Preventing cellulitis involves maintaining skin integrity and addressing underlying risk factors to reduce bacterial entry and infection risk. Evidence-based strategies emphasize proactive skin care and management of predisposing conditions, particularly for individuals with recurrent episodes or high-risk profiles such as diabetes or lymphedema.^[13] Skin care practices are foundational to prevention. Daily moisturizing with emollients helps prevent dry, cracked skin that serves as an entry point for bacteria, especially in those with chronic edema or tinea pedis.^[43] Prompt cleaning and covering of wounds or cuts minimizes infection risk, while daily inspection of the skin, particularly the feet, allows early detection of breaks or signs of infection.^[1] For at-risk groups like diabetics, wearing protective footwear and gloves during activities prevents trauma, and careful trimming of nails avoids self-injury.^[44] Mitigating specific risk factors further lowers incidence. In diabetic patients, maintaining glycemic control through diet, exercise, and medication reduces impaired immunity and skin vulnerability to infections like cellulitis.^[13] Compression therapy is recommended for individuals with lymphedema, as it reduces edema and has been shown to prevent recurrences effectively.^[23] For those with two or more episodes of cellulitis, prophylactic antibiotics such as penicillin VK (250 mg twice daily) can significantly decrease recurrence rates compared to placebo.^[45] Vaccination plays a targeted role in vulnerable populations. Immunization against Haemophilus influenzae type B (Hib) has reduced the incidence of periorbital cellulitis in children, though it does not eliminate all cases.^[46] Similarly, pneumococcal vaccines are advised for immunocompromised individuals to prevent invasive streptococcal infections that may lead to cellulitis.^[47] Lifestyle modifications support overall prevention efforts. Education on hygiene, including regular foot washing and treating fungal infections, enhances adherence to preventive measures.^[43] Avoiding barefoot walking, especially in high-risk environments or for diabetics, prevents skin breaks from trauma or contamination.^[48] Public health initiatives focus on early identification of chronic conditions. Screening for edema, venous insufficiency, or diabetes in at-risk communities allows timely intervention to manage these factors and avert cellulitis onset.^[13]

Epidemiology and Prognosis

Epidemiology

Cellulitis is a common bacterial skin infection with a global burden significant enough to warrant inclusion in major disease studies. According to analyses of the Global Burden of Disease study, there were about 54.84 million incident cases worldwide in 2019 (95% UI: 51.58–58.02 million), corresponding to an age-standardized rate of approximately 713 per 100,000 population.^[49] From 2010 to 2021, the age-standardized incidence in the United States rose by 18.5%, reflecting broader trends driven by aging populations, increasing diabetes prevalence, and environmental factors.^[50] Demographically, cellulitis predominantly affects adults over 45 years of age, with incidence rates increasing with age due to factors like reduced skin integrity and comorbidities.^[3] The lower extremities are the most common site of infection, accounting for the majority of cases.^[3] Geographically, variations in etiology contribute to differences in burden; for instance, methicillin-resistant Staphylococcus aureus (MRSA) accounts for up to 47% of S. aureus isolates causing cellulitis in North America, compared to about 27% in Europe, reflecting disparities in antibiotic use and community transmission patterns.^[51] Incidence also shows seasonal patterns, with peaks during warmer months attributed to increased skin exposure and sweating, though streptococcal cases may rise in winter in colder climates.^[20] Over time, cellulitis incidence has risen, driven by aging populations, the growing prevalence of diabetes, and the post-2000 surge in community-acquired MRSA infections, leading to more severe presentations.^[52] In the United States, hospitalizations for cellulitis doubled from approximately 300,000 in 1998 to 537,000 in 2013, with an overall admission rate of 10-20% among diagnosed cases.^[53]^[54] This contributes to significant morbidity, including an economic burden exceeding $3.7 billion annually in ambulatory care costs in the US, compounded by lost productivity from workdays.^[3]

Prognosis

With appropriate antibiotic therapy, most cases of uncomplicated cellulitis show significant improvement within 48 to 72 hours, and symptoms typically resolve within 7 to 10 days.^[55] However, swelling and residual inflammation, especially in lower extremities, may persist for weeks.^[56] Early intervention is crucial, as prompt treatment reduces the risk of progression and improves overall outcomes.^[1] Recurrence is common, affecting 20% to 30% of patients within 3 years, with rates rising to 45% or higher in those with predisposing conditions such as lymphedema, obesity, or venous insufficiency.^[13] Comorbidities like diabetes or immunosuppression further worsen prognosis by increasing susceptibility to repeated episodes and complications.^[22] Mortality remains low at less than 1% for uncomplicated cases but can be higher, up to 20-30% in bacteremic cases depending on the pathogen and patient comorbidities.^[57]^[58] In the long term, some patients develop chronic edema or scarring in the affected area, potentially leading to ongoing lymphatic dysfunction and heightened recurrence risk.^[1] Managing underlying factors, such as weight control and skin care, can mitigate these effects and support better long-term recovery.^[13]

Veterinary Medicine

Cellulitis in Animals

Cellulitis in animals refers to a bacterial infection of the subcutaneous tissues, commonly affecting companion animals such as dogs and cats, as well as livestock like horses. In dogs and cats, it frequently arises from trauma, including bite wounds or penetrating injuries, leading to localized swelling of the limbs or other affected areas.^[59] These infections often develop rapidly due to the entry of opportunistic bacteria through disrupted skin barriers.^[60] Common pathogens vary by species; in cats, Pasteurella species predominate, particularly in fight-related wounds that progress to cellulitis or abscesses.^[61] In dogs, Staphylococcus species, such as Staphylococcus pseudintermedius, and Streptococcus species are the primary culprits, often entering via cuts or abrasions.^[60] For horses, cellulitis is typically caused by Staphylococcus or Streptococcus bacteria invading through minor skin breaks.^[62] Clinical features in affected animals include painful swelling, heat, and redness at the site, often accompanied by fever, lethargy, and lameness in limb cases.^[59] Abscess formation with pus discharge may occur, particularly in cats, while horses often exhibit severe hindlimb edema and pitting that persists upon pressure.^[63] The condition tends to be more aggressive in immunocompromised animals, such as those with underlying diseases like demodicosis or diabetes, leading to rapid progression and potential systemic involvement.^[64] Diagnosis mirrors approaches in human medicine but emphasizes veterinary-specific techniques, including clinical examination, history review, and cytology from fine-needle aspirates to identify bacterial rods or cocci amid neutrophils.^[65] Bacterial cultures from wound aspirates guide targeted therapy, while imaging may rule out deeper involvement in horses.^[66] Treatment centers on systemic antibiotics, such as amoxicillin-clavulanate for dogs and cats to cover common pathogens like Pasteurella and Staphylococcus, administered for 7-14 days based on culture results.^[61] Surgical drainage is essential for abscesses, performed under anesthesia to flush and debride, while horses may receive penicillin or trimethoprim-sulfamethoxazole alongside anti-inflammatories like phenylbutazone.^[63] Supportive care includes cold hosing, bandaging, and pain management to promote resolution, with most cases healing within 1-2 weeks if addressed promptly.^[66]

Differences from Human Cases

Cellulitis in animals differs from human cases in several key aspects, including etiology, common pathogens, clinical presentation, and predisposing factors. While human cellulitis is invariably a bacterial infection of the dermis and subcutaneous tissues, primarily caused by Streptococcus pyogenes or Staphylococcus aureus, animal cases can include non-infectious or immune-mediated forms, such as canine juvenile cellulitis (also known as puppy strangles), which affects puppies under four months of age and is characterized by sterile granulomatous dermatitis and lymphadenitis without an initial bacterial cause.^[67] In this condition, inflammation arises from an idiopathic or immune-mediated process, often leading to secondary bacterial infections, and is treated with corticosteroids rather than antibiotics alone, contrasting with the purely antimicrobial approach in humans.^[67] Pathogens in veterinary cellulitis overlap with human ones but show species-specific variations that influence transmission and severity. In dogs and cats, Staphylococcus pseudintermedius is a predominant cause, particularly in canine pyoderma-associated cellulitis, differing from the human-dominant S. aureus and posing a zoonotic risk through direct contact or bites.^[59] In horses, cellulitis frequently involves streptococci alongside S. aureus, often triggered by minor trauma, and commonly manifests as acute, severe hindlimb swelling with lymphangitis, leading to pronounced lameness not typically seen in human lower-extremity cases.^[62] Poultry and swine exhibit distinct forms, such as Clostridium perfringens-induced gangrenous dermatitis in broilers or Erysipelothrix rhusiopathiae infections in pigs, which can cause diamond-skin lesions and are highly zoonotic, unlike the more uniform streptococcal-staphylococcal profile in humans.^[68]^[69] Predisposing factors also diverge, with animal cellulitis more frequently linked to environmental trauma, such as bite wounds, foreign bodies, or soil contamination, whereas human cases are often associated with comorbidities like diabetes, venous insufficiency, or immunosuppression. In equine cases, recurrent episodes may stem from lymphatic drainage issues or "stocking up" (non-septic edema), which can mimic but differ from infectious cellulitis and require differentiation via culture.^[62] Additionally, veterinary cases carry a higher risk of complications like necrosis or systemic spread due to delayed presentation in animals, and treatments emphasize surgical drainage of abscesses alongside antibiotics, with a noted potential for human transmission from infected pets.^[59]

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[PDF] Limb cellulitis in rural setting in India: a case control study
Jun 27, 2017 · Commonest risk factor was bare foot working while least common was venous insufficiency. Right lower limb was frequently affected. Local swab ...
[20]
Diagnosis and management of cellulitis - PMC - NIH
Cellulitis is simply defined as an acute infection of the skin involving the dermis and subcutaneous tissues.Cellulitis Mimics · Stratifying Risk · Treatment
[21]
Acute cellulitis and erysipelas in adults: Treatment - UpToDate
Jun 13, 2025 · ... complications of pressure-induced skin and soft tissue injury · Infectious complications of puncture wounds · Intertrigo · Invasive group A ...
[22]
Skin and Soft Tissue Infections - IDSA
Jul 15, 2014 · For cellulitis with systemic signs of infection (moderate nonpurulent; Figure 1), systemic antibiotics are indicated.
[23]
Periorbital Cellulitis - StatPearls - NCBI Bookshelf - NIH
Periorbital cellulitis is most common in children aged 5 or younger and is typically caused by trauma, insect bites, or contiguous dissemination from ...
[24]
Cellulitis and skin abscess: Epidemiology, microbiology, clinical ...
Jun 17, 2024 · (See 'Differential diagnosis' below.) The epidemiology, microbiology, clinical manifestations, and diagnosis of cellulitis and skin abscess are ...
[25]
Cellulitis: Symptoms, Causes, Treatment and more - DermNet
Cellulitis is often diagnosed when another inflammatory skin disease is actually responsible for redness and swelling. Conditions causing 'pseudocellulitis' ...
[26]
Lipodermatosclerosis - DermNet
Acute phase. Acute lipodermatosclerosis may mimic cellulitis, with induration, erythema, pain, itch, aching, and a feeling of swelling ...
[27]
Alternative Diagnoses That Often Mimic Cellulitis - AAFP
Jun 15, 2003 · We have suspected that many of the presentations labeled as cellulitis may represent alternative diagnoses that are often treatable.
[28]
Is It Cellulitis or Something Else? - Everyday Health
Shingles Can Mimic Cellulitis. Herpes zoster, the viral infection also known as shingles, can be mistaken for cellulitis. Shingles is caused by the varicella ...
[29]
Distinguishing Periorbital from Orbital Cellulitis - AAFP
Mar 15, 2003 · The clinical signs help to distinguish periorbital from orbital cellulitis. Periorbital infection causes erythema, induration, and tenderness ...
[30]
Utility of Inflammatory Markers in Hospitalized Children With Skin ...
Among patients presenting with skin erythema, CRP ≥2 mg/dL and ESR ≥30 mm/hr were significantly associated with deeper infection.
[31]
Serum Procalcitonin Level Reflects the Severity of Cellulitis - PMC
Nov 23, 2016 · White blood cell (WBC) count, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are often used as markers of bacterial infection ...
[32]
Low yield of blood and wound cultures in patients with skin and soft ...
Of 86 (35.0%) patients who had blood cultures, six had positive cultures (yield=7.0%; 95% confidence intervals [CIs] 3.2-14.4); 4 were methicillin sensitive ...Missing: cellulitis | Show results with:cellulitis
[33]
Ultrasound for the Evaluation of Skin and Soft Tissue Infections - NIH
Ultrasound is a valuable tool in the evaluation of skin and soft tissue infections, enhancing our ability to diagnose an abscess cavity or deeper infection.
[34]
Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice
Nov 25, 2022 · MRI is considered the most comprehensive and sensitive imaging tool available for the assessment of musculoskeletal infections.2.1. Cellulitis · 2.2. Necrotizing And... · 2.4. Abscess
[35]
PCR Offers No Advantage Over Culture for Microbiologic Diagnosis ...
Jul 17, 2012 · Conclusions: PCR-based techniques do not appear to be more sensitive than aspirate cultures for the detection of pathogens in cellulitis.
[36]
Guidelines Summary, Nonpurulent Cellulitis, Purulent Cellulitis
Dec 30, 2024 · IDSA guidelines recommend oral dicloxacillin or IV nafcillin or oxacillin as the drugs of choice, but note that nafcillin and oxacillin are ...
[37]
Cellulitis | Johns Hopkins ABX Guide
Jul 12, 2025 · Some now favor using linezolid for severe GAS infections instead of clindamycin due to rising rates of resistance among S. pyogenes. Clindamycin.
[38]
Clinical Guidance for Group A Streptococcal Cellulitis - CDC
Aug 5, 2025 · Multiple bacteria can cause cellulitis. Cellulitis typically involves erythema, pain, and warmth locally and can include systemic symptoms.
[39]
Patients' understanding of cellulitis and views about how best to ...
Enhanced foot hygiene, applying emollients daily and exercise appeared to be more acceptable prevention strategies than compression or long‐term antibiotics.
[40]
Cellulitis: How to prevent recurrent episodes - Mayo Clinic
Swelling of a limb caused by trapped fluid (edema). If you frequently develop cellulitis, your doctor might recommend long-term antibiotic treatment to prevent ...
[41]
Interventions for the prevention of recurrent erysipelas and cellulitis
Most guidelines advocate antibiotic prophylaxis with penicillin, but differ widely on the best time to start treatment and its duration.
[42]
Preseptal and orbital cellulitis in childhood. A changing ... - PubMed
Conclusion: The incidence of hemophilus-associated bacteremia in patients with preseptal cellulitis has decreased dramatically over the past 10 years.
[43]
Modeling the potential health impact of prospective Strep A vaccines
Jun 10, 2023 · The long-term strategic goal is to develop a safe, globally effective, and affordable Strep A vaccine to prevent acute Strep A infections ( ...
[44]
Early intervention and care for Diabetic Foot Ulcers in Low and ...
Apr 29, 2024 · Inadequate hygiene practices encompass ill‐fitting footwear, walking barefoot outdoors, infrequent foot washing, and limited access to ...
[45]
Assessment of Public Awareness of Cellulitis in Al-Qunfudhah ...
Jun 25, 2024 · Worldwide, about 200 cases of cellulitis per 100,000 patients are registered per year, which is much lower than assessed in the current ...
[46]
Cellulitis and erysipelas - Symptoms, Causes, Images ... - Epocrates
The Global Burden of Disease project estimated that 56 million cases of cellulitis (678.4 per 100,000 population) occurred in 2021, causing 28,900 deaths.[3].<|separator|>
[47]
Cellulitis incidence in a defined population - PMC - NIH
We found a cellulitis incidence rate of 24·6/1000 person-years, with a higher incidence among males and individuals aged 45–64 years.Methods · Results · Discussion
[48]
Twenty-Year Trends in Antimicrobial Susceptibilities Among ...
Mar 15, 2019 · The percentage of MRSA among all S. aureus isolates varied geographically, from 26.8% in Europe to 47.0% in North America (Figure 1).
[49]
Increasing Incidence, Cost, and Seasonality in Patients Hospitalized ...
... hospitalization and the increase in cost from hospitalized care for cellulitis. ... National trends in Staphylococcus aureus infection rates: impact on economic ...
[50]
Increasing Incidence, Cost, and Seasonality in Patients Hospitalized ...
Feb 8, 2017 · In 1998, there were approximately 300 000 adult cellulitis hospitalizations nationally. In 2013, this number increased to approximately 537 000.
[51]
Analysis of Readmissions Following Hospitalization for Cellulitis in ...
Feb 27, 2019 · Of the 2.9 million patients presenting annually to US emergency departments for cellulitis, 12.9% are admitted to the hospital. However, the ...<|separator|>
[52]
Cellulitis: How long does it take to heal on legs? - Harvard Health
Nov 20, 2023 · After starting antibiotic treatment, people usually notice improvement within a few days. However, the area may remain swollen, warm, and painful even after 10 ...
[53]
Do Patients with Cellulitis Need to be Hospitalized? A Systematic ...
Jul 18, 2018 · The overall pooled rate was 1.1% (95% CI, 0.7–1.8). Individual studies ranged from 0 deaths to 2.9% mortality.
[54]
Bacteremic pneumococcal cellulitis compared with ... - PubMed
The 30-day mortality was 10% in patients with pneumococcal cellulitis, 13% in patients with Staphylococcus aureus cellulitis, and 23% in patients with ...
[55]
Cellulitis in Dogs and Cats - Veterinary Partner - VIN
Jul 19, 2023 · Cellulitis is a painful inflammation of the tissue under the skin. In animals, it is generally caused by a bacterial infection that has entered the skin from a ...
[56]
Cellulitis in Dogs Explained | Symptoms & Treatments - GeniusVets
Cellulitis in dogs is a painful inflammation beneath the skin's surface that can arise due to bacterial infections entering through cuts, open wounds, or skin ...
[57]
Fight Wound Infections in Cats | VCA Animal Hospitals
With appropriate treatment, most abscesses should heal within five to seven days. The swelling associated with cellulitis may take longer. If you believe the ...
[58]
Cellulitis in Horses - WestVETS Animal Hospital
Cellulitis and lymphangitis are relatively common in the horse. They are bacterial infections within the skin, subcutaneous tissue and sometimes involve the ...
[59]
Cellulitis in Horses - PetMD
Feb 16, 2023 · Cellulitis is a bacterial infection, so the primary treatment is antibiotics. Additionally, your veterinarian will likely recommend a medication ...
[60]
Treating Resistant Skin Infections in Dogs | Today's Veterinary Practice
The major canine skin pathogen is S pseudintermedius;11 however, Staphylococcus schleiferi, Staphylococcus aureus, and Pseudomonas aeruginosa have also been ...
[61]
Skin “Lumps and Bumps” Cytology - Today's Veterinary Practice
Aug 11, 2023 · This article briefly reviews the broad categories of skin “lumps and bumps” cytology, including features of hyperplastic, inflammatory, neoplastic, and cystic ...
[62]
Severe Skin Infection of the Horse's Legs Called Cellulitis
Apr 26, 2018 · Treatment includes intravenous antibiotics, anti-inflammatories and cold hosing to help remove the swelling. Once the horse has less pain, ...
[63]
Juvenile Cellulitis (Puppy Strangles) - VCA Animal Hospitals
Although a bacterial infection does not cause juvenile cellulitis, secondary bacterial infections often develop in the open skin lesions. Treating these ...
[64]
Gangrenous Dermatitis in Poultry - Merck Veterinary Manual
Gangrenous (GD) dermatitis is a disease of poultry, primarily commercial broiler chickens and turkeys.
[65]
Overview of Erysipelothrix rhusiopathiae Infection in Animals
As a zoonosis, E rhusiopathiae infection manifests as erysipeloid, a human condition characterized by localized skin infections and cellulitis. Erysipeloid ...