Facial cellulitis

Background

• Superficial soft tissue infection of the face
• Most commonly caused by S. pyogenes and S. aureus, including MRSA

Risk Factors

• immunosuppression
• diabetes
• vascular injury (due to radiation or trauma)
• foreign bodies

Clinical Features

• Erythema, edema, warmth, pain
• Can be associated with chronic illness, trauma, insect bites, allergen exposure, dental caries, radiation exposure
• Consider severe illness or sepsis with systemic symptoms (fever, tachycardia, hypotension, AMS)

Differential Diagnosis

Facial cellulitis

Infectious

• Cellulitis
• Impetigo
• Erysipelas
• Viral exanthem
• Parotitis
• Necrotizing fasciitis
• Anthrax
• Herpes zoster
• Malignant otitis externa

Trauma

• Soft tissue contusion
• Burn

Inflammatory

• Insect bite
• Apical abscess
• Contact dermatitis

Immunologic

• Systemic lupus erythematosus
• Vancomycin flushing reaction
• Angioneurotic edema

Skin and Soft Tissue Infection

• Cellulitis
  • Hand cellulitis
  • Facial cellulitis
• Erysipelas
• Lymphangitis
• Abscess
  • Bartholin gland abscess
• Necrotizing soft tissue infections
  • Necrotizing fasciitis
  • Necrotizing myositis
  • Necrotizing cellulitis
• Mycobacterium marinum

Look-A-Likes

• Sporotrichosis
• Osteomyelitis
• Deep venous thrombosis
• Pyomyositis

Evaluation

• Diagnosis is clinical
• Consider labs, blood culture if patient is immunocompromised, risk factors, renal dysfunction
• Bedside ultrasound to identify abscess
• CT can identify deep, extensive infection that involve soft tissues of neck or pharynx

Management

1. Analgesics
2. Remove foreign bodies from affected area if possible
3. Abscesses should be drained
4. Antibiotics (see below)

Antibiotics

Tailor antibiotics by regional antibiogram

Outpatient

Coverage primarily for Strep

MRSA coverage only necessary if cellulitis associated with: purulence, penetrating trauma, known MRSA colonization, IV drug use, or SIRS

• 5 day treatment duration, unless symptoms do not improve within that timeframe
  • Cephalexin 500mg PO q6hrs OR
    • Add TMP/SMX 1DS PO BID if MRSA is suspected
    • Most cases of non-purulent cellulitis are thought caused by Strep. In these cases, the addition of TMP/SMX has been demonstrated to offer no clinical benefit over cephalexin alone.
  • Clindamycin 450mg PO TID
  • Tetracyclines (like Doxycycline) should be avoided in non-purulent cellulitis, due to high rates of Strep resistance

Inpatient

• Vancomycin 20mg/kg IV q12hrs OR
• Clindamycin 600mg IV q8hrs OR
• Linezolid 600mg IV q12hrs OR
• Daptomycin 4mg/kg IV once daily

Saltwater related cellulitis

coverage extended for Vibrio vulnificus

• Doxycycline 100mg PO/IV q12hrs daily + Cefepime 1g IV q12hrs x 10 days
• Ciprofloxacin 400mg IV q12hrs x 10 days
• Ciprofloxacin 750mg PO q12hrs x 10 days

Freshwater related cellulitis

coverage extended for Aeromonas sp

• Ciprofloxacin 400mg IV q12hrs x 10 days
• Ciprofloxacin 500mg PO q12hrs x 10 days
• TMP/SMX 2 DS tablets (5mg/kg) PO q12hrs x 10 days
• Ceftriaxone 1g (50mg/kg) IV q24hrs

Disposition

• Most patients can be treated with oral antibiotics as outpatient

Consider admission for:

• systemic signs of sepsis
• antibiotic intolerance
• immunosuppression
• extensive areas of erythema or induration
• foreign bodies that cannot be removed in ED
• failure of outpatient therapy

See Also

• Cellulitis

References

Authors

Kaoru Itakura, Ross Donaldson, Neil Young, Daniel Ostermayer, Claire