Recurrent erysipelas A46

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 05.02.2023

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Synonym(s)

Chronic erysipelas; Erysipelas recidivans; recurrent celulitis; recurrent erysipelas; Recurrent erysipelas

Definition
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Erysipelas recurring at irregular intervals.

Etiopathogenesis
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Congenital or acquired lymphatic drainage disorders. Partial immunodeficiency of the organism to streptococcal antigen.

The following anamnestic and clinical data are associated with an increased risk of recurrence:

Chronic lymphedema (most important predictor).
Localization: Lower leg
Previous tumor disease with consecutive lymphatic drainage disorder (e.g., breast carcinoma with lyphadenectomy).
Previous saphenectomy due to coronary bypass surgery.
Chronic eczema (e.g., stasis eczema).
Chronic venous insufficiency.

Another possible cause of recurrence is intracellular uptake and persistence of streptococci. Because β-lactam antibiotics achieve bactericidal concentrations only in the extracellular space, it may require the additional use of intracellularly active antibiotics, such as clindamycin, macrolides, and rifampicin. The combination of clindamycin or rifampicin together with penicillin currently proves to be the most effective combination for the treatment of infections with group A streptococci.

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Clinical features
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First recurrences occur with analogous clinical symptoms as the primary manifestation. With increasing recurrence frequency, the acute nature of the infection disappears. Only a discrete redness and overheating, possibly complete absence of fever and leucocytosis is observed. In most cases, an initially discreet lymphedema persists, which becomes more pronounced with increasing recurrence frequency.

Complication(s)
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Persistent lymphedema, consecutive sclerosis, pigmentary shifts, pachydermia, elephantiasis inflammatoria.

Therapy
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In the acute stage antibiotics. S.u. Erysipelas.
For underlying or secondary lymphatic drainage disorders, compression therapy with elastic short-stretch bandages and manual and, if necessary, additional intermittent lymphatic drainage by apparatus (30 min/day).
Notice!
Lymphatic drainage in case of inflammation due to danger of sepsis only under antibiotic protection!
- Satisfactory long-term therapy successes are achieved by intermittent penicillin therapies (several studies with evidence level up to IIa). Therapy schedule 1: Penicillin G every 3 months (10 million IU/day penicillin i.v. over 10 days); treatment period: 1 year.
- Therapy schedule 2: Penicillin V 250mg 2x/day p.o. for a period of 6 months. In this study (123 patients) the risk of recurrence was reduced by about 50%.
- Therapy regimen 3: Tardocillin 2,4 (1,2 each gluteal left and right) i.m. every 4 weeks
- In case of penicillin intolerance use Erythromycin 2 times/day 1 g i.v. for 10 days or Cephalosporins ( Ceftriaxon 2g i.v./day).

Literature
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Chlebicki MPet al. (2014) Recurrent cellulitis: risk factors, etiology,pathogenesis and treatment. Curr Infect Dis Rep 16:422
Inghammar M et al (2014) Recurrent erysipelas--risk factors andclinical
presentation. BMC Infect Dis 14: 270
McNamara DR et al (2007) A predictive model of recurrent lower extremity cellulitis in a population-based cohort. Arch Internal Med 167: 709-715
Thomas K et al(2012) Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the UK Dermatology Clinical Trials Network's PATCH II trial. Br J Dermatol 166:169-178.