Recurrent Cellulitis

Refer to cellulitis pathway for signs and symptoms, possible investigations and differential diagnosis of cellulitis.

Patient with recurrent cellulitis may be:

• Already diagnosed as having lymphoedema
• At risk of lymphoedema with evidence of possible lymphatic compromise:
  • Lymph node removal and/or irradiation
  • Obstructive/advanced malignant disease
  • Chronic venous disease
  • Family history of lymphoedema
• Chronic ulceration, wound infection or inflammatory skin condition damaging local lymphatics.

Additional information:

• Cellulitis is both a symptom and cause of lymphoedema
• Medications such as corticosteroids or cancer treatment, may alter the presentation of cellulitis
• Effective use of decongestive and compression therapy is essential in managing oedema, ulceration and skin problems that may lead to recurrent cellulitis: consider referral to lymphoedema practitioner.

Hospital admission is required if:

• Severe systemic signs/sepsis syndrome, which may include:
  • Severe localised pain
  • Confusion
  • Systolic BP less than 100mmHG
  • Sepsis syndrome, any 2 of:
    • heart rate greater than 100
    • resp rate greater than 20/min
    • temp higher than 38^oC or lower than 36^oC
    • white cell count higher than 12 or less than 4/mm³
  • Rapidly evolving skin lesions or skin blistering
  • Vomiting
• Deteriorating systemic signs, with or without local signs, after 48 hours or oral antibiotic treatment.

• History of cellulitis: patient should carry a supply of antibiotics, particularly if away from home for any length of time
• Prescribe two week supply of ‘just-in-case’ flucloxicillin 500mg four times a day.
• Allergic to penicillin: give clarithromycin 500 mg twice daily or doxycycline 200mg stat, then 100mg twice daily
• Advise patient to start antibiotics immediately when familiar symptoms of cellulitis develop; and to see a doctor as soon as possible.

Self-care advice and treatment to reduce the risk of cellulitis:

• Wash the skin daily and pat dry with a clean, soft towel
• Keep the skin well moisturised: daily use of a bland emollient such as Diprobase ® Cream or Epaderm ® Ointment (refer to Highland Formulary)
• Consider emollient bath additive with antimicrobials such as Emulsiderm ® OTC or similar shower gel such as Dermol ®
• Protect from burns, injury, bites, sunburn, scratches using appropriate skin cover, gardening gloves, and insect repellent
• Tinea pedis should be actively treated: application of terbinafine otc cream once or twice daily for two weeks (or refer to Highland Formulary). Follow by maintenance treatment, using cream or powder such as miconazole nitrate spray
• Fungal infection of nails: send nail clippings to mycology; consider amorolfine otc nail lacquer.
• Some patients who have had one or more episodes of cellulitis can benefit from “just in case” antibiotics or antibiotic prophylaxis (refer to recurrent cellulitis guidance)

Those at risk of further cellulitis episodes include individuals with:

• Skin and tissue problems: dermatitis, weeping eczema, open wounds
• Poorly managed oedema
• Tinea pedis and/or maceration between the toes
• Poorly resolved infection, due to inadequate length of antibiotic treatment.