Medical symptom checker - Butterfly rash on face - Erysipelas


Erysipelas which also known as Saint Anthony’s fire is mostly acute infection, but chronic recurrent episodes of infection do exist. It is a well demarcated superficial bacterial skin infection with involvement of lymphatic system. It is caused by bacterial known as streptococcus pyogenes. Erysipelas will affect the skins and exocrine system.

Recurrent infection mostly present in male who shave after 5 days of facial erysipelas.Other possible source of infection by streptococcal includes toenails, sinus, tonsil and teeth needs to be investigated for recurrent episodes of erysipelas. Maintenance antibiotic is required for recurrent infection of erysipelas and suppressive prophylatic antibiotics are required for patients with more than 2 episodes of erysipelas in a year period.

In term of epidemiology, the prevalence and incidence of erysipelas remain unknown. However erysipelas affects all race, affect men and women and affect elderly people more than 75 years the most, as well as adult more than 40 years old, infants and children.

The risk factors for developing erysipelas are fissured in the skin such as ear and nose, any disruption to the skin barrier such as abrasion, local trauma, surgical incision, fungal infection, insect bites and toe web intertrigo, any cause of malnutrition, diabetes or nephrotic syndrome, ( chronic disease ) , delibitated or immunocompromised patients, recent streptococcal pharyngitis, morbid obese and alcohol abuse. Other cause include lymphatic and venous insufficiency as a result from radiotherapy, lymphadectomy and saphenectomy and stasis dermatitis and leg ulcers.

Erysipelas is most commonly caused by Group A beta hemolytic streptococci. Other includes streptococcus Group G and streptococcus Group c. Group B streptococcus rarely cause erysipelas as well as staphylococcus aureus. However group B streptococcus is the most common cause of erysipelas in infants and neonates.

Patient initially complains of moderate and high grade fever, vomiting, chills, headache and anorexia during the first 48 hours. All these symptoms are known as systemic prodromal symptoms. This will follow by acute onset of well sharp demarcated, deep, shiny, raised border plaque which spreads circumferentially over hours to days. The lesions also indurated ( Peau de Orange ) , hot and marked swelling with centre of the lesions is clear with periphery spreads.

Headache and vomiting are prominent with itchiness/pruritus and pain in the joints or arthralgia. Patient also complains of facial redness, discomfort of the skin and formation bullae and vesicles which are not uniformly present. Desquamation of the skin may occur. Most commonly affects the lower extremity ( 70%-80& ) and face involvement is around 5% to 20% mostly nose and ears. After initial episodes, chronic infection may recur hours to years after initial episodes and recurs at the sites of previous infection.

Fever is the factor that differentiate erysipelas from other skin problems. The usage of systemic corticosteroids may mask the symptoms/ systemic effect of erysipelas which make it difficult to diagnose erysipelas. The systemic toxicity will rapidly reduced with treatment and the desquamousation of the skin will follows after 10- 14 days of treatments.

In term of pediatric consideration, children with erysipelas will complain of abdominal discomfort, formation of skin lesions of the leg, scalp and face and the present of umbilical stump.

In term of geriatic / elderly consideration, they are more prone to complication than fever. In patient with cardiac disease and debilitated condition there will be an increase in the cardiac output which leads to cardiac failure. Lower extremity and face are the most common areas affected.

In term of examination, patient is tachycardic with moderate to high grade fever. Hypotension may also occurs. On palpation , the lesions appears as erythematous , tender, hot and sharply demarcated borders plaque.It is present as butterfly rash in the face. Lymphadenopathy , peau de orange and lymphangitid streaking are rare.

Most cases of erysipelas are diagnosed based on clinical examination. The diagnostic test is reserved for severely ill and toxic patient who appear to be immunocompromised.

In this case, the blood test will reveals leukocytosis and less than 5% of blood culture are positive. The culture of streptococci may be taken from non infected sites or exudates. Anti - DNase and anti streptolysin streptoenzyme are also helpful diagnostic test. High ASO titers and high anti DNase level are helpful in diagnosing erysipelas.

Pathologically , erysipelas involves vasolidation, enlarged lymphatic, endothelial swelling, infiltration of lymphocytes, leukocytes and other inflammatory cells and edema caused by invasion of local blood vessel by rare bacterial known as gram positive cocci.

The differential diagnosis of erysipelas includes systemic lupus erythematosus, tuberculoid leprosy, scarlet fever, polychondritis, giant cell urticaria, dermatophytes , herpes zoster, inflammatory breast carcinoma and necrotizing fasciitis.

The treatment usually involves penicillins, either orally or parenterally depending on how severe erysipelas clinically. Most of the cases are managed in an outpatient department. Generally the treatment focus on adequate intake of fluid, symptomatic relief of acne and fever with cold compression. It is suggested that the patient consider bed rest and intravenous fluid therapy in case of systemic toxicity.

The first line of drug for adult include treatment with penicillin V for 10- 14 days with 24 - 48 hours of improvement. Penicillin G is reserve for severe and complicated case. Besides that nafcillin or oxacillin or even penicillin G is also recommended for severe complicated cases in parenterally. In case of recurrent infection maintenance antibiotic of lower dose or prophylatics suppression antibiotic is recommended after acute infection.

The second line of drug includes macrolide for patient who is allergic to penicillin such as azithromycin and erythromycin. For suspected staphylococcal infection first generation cephalosporin is required that includes cefazolin and cephalexin. In case of staphylococcal infection that affect the face consider dicloxacillin or first generation cephalosporin. Penicillin V ,azithromycin, erythromycin and clarithromycin are considered in recurrent case of erysipelas in adult.

Patient is admitted to the hospital in case of development of systemic toxic side effect, high risk patient with chronic diseases ( diabetes) , lower immunity ( post splenectomy ) , elderly, or present of lymphedema.

Patient is discharged when there is no signs or symptoms of systemic toxicity and the swelling as well as the erythema are improving.

Patient is refer to the hospital when treatment of erysipelas is failing to improve the patient condition and the patient suffer from recurrent episodes of erysipelas.

In term of prognosis , patient will achieve full recovery ( some cases will resolve spontaneously without treatment ) with proper and adequate treatment . Chronic recurrent cases may leads to scarring, elephantiasis and edema as well as bullae.

The complication includes meningitis, septic arthritis, sepsis, bacteremia, abscess, pneumonia, Scarlet fever and embolism.

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