Cellulitis: Difference between revisions

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<div class="noeditbox">Welcome to [[Pathophysiology of Complex Patient Problems|PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
<div class="noeditbox">Welcome to &lt;a href="Pathophysiology of Complex Patient Problems"&gt;PT 635 Pathophysiology of Complex Patient Problems&lt;/a&gt; This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
'''Original Editors '''- [[Pathophysiology of Complex Patient Problems|Students from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]
'''Original Editors '''- &lt;a href="Pathophysiology of Complex Patient Problems"&gt;Students from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.&lt;/a&gt;


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== Definition/Description  ==
== Definition/Description  ==


Cellulitis is a '''localized bacterial skin infection''', which typically affects the lower limbs but can occur on any area of skin and underlying subcutaneous tissue &nbsp;It is characterized by acute onset of&nbsp;'''redness, inflammation, pain, and swelling '''of the affected area. Accompanying symptoms include generalized fever, rigors, nausea, and vomiting<ref name="Mason">Mason JM, Thomas KS, Crook AM, Foster KA, Chalmers JR, et al. Prophylactic Antibiotics to Prevent Cellulitis of the Leg: Economic Analysis of the PATCH I &amp;amp;amp; II Trials. PLoS ONE. 2014;9(2):e82694 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0082694 (accessed 28 Feb 2017).</ref>.&nbsp;The infection is most commonly caused by B-Hemolytic Streptococci bacteria and reoccurs up to 50% of the time in the lower extremity.<ref name="Tsai">Tsai C-YL, Calvin MK, Chung C, Susan Shin-Jung L, Yao-Shen C, Hung C. Development of a prediction model for bacteremia in hospitalized adults with cellulitis to aid in the efficient use of blood cultures: a retrospective cohort study. BMC Infectious Diseases. 2016;16(1):581. https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-016-1907-2 (accessed 27 Feb 2017).</ref>&nbsp;Most individuals diagnosed with cellulitis have a low risk of severe complications but few suffers can have severe sepsis, local gangrene, and/or necrotising fasciitis.<ref name="Mason" /><br><br>
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[[Image:Mild cellulitis.jpg|center|250x200px]]
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; A mild case of cellulitis<ref name="Medscape">Medscape. Cellulitis. http://emedicine.medscape.com/article/214222-overview (accessed 27 Feb 2017).</ref>
 
[[Image:Severe cellulitis.jpg|center|250x200px]]
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; A severe case of cellulitis that developed under a cast<ref name="Medscape" /><br>
 
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== Prevalence  ==
== Prevalence  ==


*650,000 hospital admissions per year in the United States are due to cellulitis.<ref>Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016;316(3):325-37. http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/935437/ (accessed 27 Feb 2017).</ref>
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*When hospitalized, patients with recurrent cellulitis require longer hospitalizations relative to nonrelapsing cellulitis patients.<ref name="Raff" />
*From 1998-2006, '''10% of all infectious-disease hospitalizations '''were related to cellulitis<ref name="Raff" />
*22-49% of patients who have cellulitis report at least one previous episode<ref name="Raff" />
*Recurrences, typically in the same location, occur approximately 14% of cellulitis cases within 1 year and in 45% of cases within 3 years<ref name="Raff" /><br>


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


Typical symptoms include acute poorly demarcated and spreading erythema along with pain, swelling, and warmth of the lower extremity but can occur on any area of skin or underlying subcutaneous tissue.<ref name="Tsai" /><ref name="Raff" />&nbsp;Additional symptoms may include fever, nausea, vomiting, and rigors<ref name="Raff" />.<ref name="Kilburn">Kilburn SA, Featherstone P, Higgins B, Brindle R. Interventions for cellulitis and erysipelas. (Cochrane review). Cochrane Database Syst Rev. 2010(6):CD004299.</ref>Other features include proximal dilated and edematous skin lymphatics and bulla formation. Cellulitis predominantly has a unilateral presentation, most commonly in the lower extremity.<ref name="Raff" /><br>
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&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Classic presentation of cellulitis: poorly demarcated erythema<ref name="Bailey">Bailey E, Kroshinsky D. Cellulitis: Diagnosis and Management. Dermatologic Therapy. 2011;24:229–39.http://onlinelibrary.wiley.com/doi/10.1111/j.1529-8019.2011.01398.x/full  (accessed 15 Mar 2017).</ref>  


== Associated Co-morbidities  ==
== Associated Co-morbidities  ==


'''Diabetes Mellitus '''is one of most common comorbidities among those hospitalized for acute bacterial infections including cellulitis.<br>Following a cellulitis infection, those with diabetes require a longer course of antibiotic therapy and are more likely to have an outpatient follow up visit.<ref>Jenkins TC. Comparison of the Microbiology and Antibiotic Treatment among Diabetic and Non-Diabetic Patients Hospitalized for Cellulitis or Cutaneous Abscess. J Hosp Med. 9ADADDec12;:788–94.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4256165/ (accessed 28 Feb 2017).</ref><br>
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Lymphatic flow changes can predispose individuals to a cutaneous infection. Examples of co-morbidities that result in lymphatic flow changes include '''peripheral vascular disease, liposuction, radiation therapy, lymph node dissection,''' and '''lymphedema'''.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Bailey" /&gt;<br><br>  


== Medications  ==
== Medications  ==


Cephalexin, Dicloxacillin, Penicillin VK, Amoxicillin, and Clindamycin are typical Antistreptococcal Antimicrobial agents for the treatment of typical cellulits that is considered mild and does not show signs of systemic involvement.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Raff" /&gt;&nbsp;Table 1 states which medications would be appropriate based on the severity of symptoms and the risk of Methicillin-resistant Staphylococcus aureus (MRSA).&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Kilburn" /&gt;<br>  
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{| width="200" border="1" align="center" cellpadding="1" cellspacing="1"
|+ ''Table 1''
|-
! scope="col" | Clinical Presentation
! scope="col" | Appropriate Antibiotic Treatment
|-
| Routine Cellulitis with low suspicion of MRSA
| Dicloxacillin, Cephalexin, Nafcillin, or Cefazolin<span class="Apple-tab-span" style="white-space:pre"> </span>
|-
| High suspicion of MRSA or Penicillin allergy
| Doxycyline, Clindamyciin, Trimethoprim-sulfamethoxazole
|-
| High suspicion of MRSA with signs and symptoms of severe infection or patient did not respond to intitial routine treatment<span class="Apple-tab-span" style="white-space:pre"> </span>
| Vancomycin♦, Linezolid
|}
 
♦Vancomycin is the drug of choice for infections resulting from MRSA&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Kilburn" /&gt;


== Diagnostic Tests/Lab Tests/Lab Values  ==
== Diagnostic Tests/Lab Tests/Lab Values  ==


&nbsp; &nbsp; &nbsp; &nbsp;Cultures are typically not beneficial in making a cellulitis diagnosis. It is most commonly diagnosed by&nbsp;'''history and physical examination alone.''' Certain laboratory tests can indicate the presence of infection, but are not specific to cellulitis alone. Elevated white blood cell count, C-reactive protein, and erythrocyte sedimentation rate are the most common laboratory results in people with cellulitis, though the prevalence of these results varies widely on a case by case basis.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Raff" /&gt;Imaging studies can identify more severe infections to differentiate from cellulitis, but are not a reliable diagnostic tool for cellulitis itself.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Raff" /&gt;
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&nbsp; &nbsp; &nbsp; Identification of the cause of the infection through blood, needle aspiration or punch biopsy are not recommended unless the patient has a complication or abnormal exposure history. This would include immunosuppressants, a diagnoses of chronic liver disease, aquatic soft tissue injury, animal and human bites, or being in contact with various bacterias.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Raff" /&gt;&nbsp;If a biopsy and culture is warranted, a histopathologic evaluation will be performed on the sample. Hematoxylin-and-eosin and certain stainings for organisms, bacteria, fungi, and microbacteria will be included.<ref>McNamara DR, Tleyjeh IM, Berbari EF, Lahr BD, Martinez J, Mirzoyev SA, Baddour LM. A predictive model of recurrent lower extremity cellulitis in a population-based cohort. Arch Intern Med. 2007;167(7):709-715 http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/412163 (accessed 15 March 2017)</ref>&nbsp;<br><br>  


== Etiology/Causes  ==
== Etiology/Causes  ==


Cellulitis can be caused by various organisms but most commonly by&nbsp;'''Streptococcus pyogenes''' or '''Staphylococcus aureus'''.<ref>Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. Bmj [Internet]. 2012Jul [cited 2017Mar20];345(aug07 2):38–42. Available from: http://www.bmj.com/bmj/section-pdf/187604?path=/bmj/345/7869/Clinical_Review.full.pdffckLRMedscape. Cellulitis. http://emedicine.medscape.com/article/214222-overview (accessed 27 Feb 2017).</ref> The organisms may enter the body after a cut, bite, or wound that compromises the skin or may enter through microscopic changes in the skin. They enter the dermis and multiply to cause cellulitis.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Medscape" /&gt;&nbsp;
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Studies show&nbsp;'''lymphedema is a major risk factor '''for the development of cellulitis. There is known to be a link between the two, but it is not known which of the two comes first. Patients with lymphedema or chronic edema are more prone to infection due to damage to lymphatic vessels and immune deficiency in that area. Cellulitis on the other hand, can cause damage to the lymphatics and the development of lymphedema.<ref>Riches K, Keeley V. Cellulitis in patients with chronic oedema. Nursing &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Residential Care [serial on the Internet]. (2012, Mar), [cited March 31, 2017]; 14(3): 122-127. Available from: CINAHL with Full Text.</ref><br>  
 
&lt;img src="/images/thumb/e/e4/Cellulitis_and_lymphedema.JPG/316px-Cellulitis_and_lymphedema.JPG" _fck_mw_filename="Cellulitis and lymphedema.JPG" _fck_mw_location="center" _fck_mw_width="375" _fck_mw_height="198" alt="" class="fck_mw_center" /&gt;&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Riches" /&gt;


== Systemic Involvement  ==
== Systemic Involvement  ==


Cellulitis can be found anywhere on the skin, and can cause systemic issues in those areas. Locally, cellulitis often results in significant tissue damage in the involved area.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Tsai" /&gt;&nbsp;Cellulitis can spread systemically through the lymphatics and blood stream, which can lead to further complications.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Medscape" /&gt; If cellulitis does spread systemically through one of these systems, it can cause flu-like symptoms such as fever, rigors, nausea and vomiting.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Kilburn" /&gt;&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Riches" /&gt; Though rare, there is a risk for '''severe sepsis, gangrene, or necrotizing fasciitis''' if cellulitis spreads systemically and is left untreated.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Kilburn" /&gt; <br>
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&lt;img src="/images/thumb/0/0b/Cellulitis_Mayo.PNG/350px-Cellulitis_Mayo.PNG" _fck_mw_filename="Cellulitis Mayo.PNG" _fck_mw_location="center" _fck_mw_width="350" _fck_mw_height="250" alt="" class="fck_mw_center" /&gt;<ref>Cellulitis [Internet]. Mayo Clinic. [cited 2017Apr4]. Available from: http://www.mayoclinic.org/diseases-conditions/cellulitis/basics/definition/con-20023471</ref><br>


== Medical Management (current best evidence)  ==
== Medical Management (current best evidence)  ==


Currently, there are no published national guidelines for the treatment of cellulitis.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Tsai" /&gt; Although there are no national guidelines, there are two classification systems based on expert opinion that may be used. The&nbsp;'''Eron Classification''' system is the most widely used and is described in Table 3. A more recent classification system, The '''Dundee Classification''', was released in 2010. Table 4 compares these two classification systems based on strength of evidence, validation, and criteria.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Phoenix" /&gt;
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<br>&lt;img src="/images/a/a8/ERON_clinical_classification_system.PNG" _fck_mw_filename="ERON clinical classification system.PNG" _fck_mw_location="center" _fck_mw_width="561" _fck_mw_height="138" alt="" class="fck_mw_center" /&gt;&lt;img src="/images/1/13/ERON_classification_vs_Dundee_classification.PNG" _fck_mw_filename="ERON classification vs Dundee classification.PNG" _fck_mw_location="center" _fck_mw_width="565" _fck_mw_height="154" alt="" class="fck_mw_center" /&gt;<br>
 
Most common management of the infection is administration of '''antibiotics'''. In more severe cases of cellulitis, intravenous antibiotics can be used.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="McNamara" /&gt;&nbsp;Elevation and compression of the affected area promotes drainage of edema and can reduce inflammation, speeding up recovery.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="McNamara" /&gt;
 
For those with recurrent cellulitis, prophylactic antibiotic therapy is an option. Recent studies show that antibiotic prophylaxis substantially reduced the number or recurrences experienced by patients while actively taking the medication. Although there is reduction during the antibiotic therapy, there is no evidence of persistent protect effect after it has ceased.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mason" /&gt;<br>
 
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Below is a treatment algorithm for Non-purulent Cellulitis, as described by Raff et. al.&nbsp;&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Raff" /&gt;
 
&lt;img src="/images/0/07/Medicalmanagementcellulitis.jpg" _fck_mw_filename="Medicalmanagementcellulitis.jpg" _fck_mw_location="center" _fck_mw_width="650" _fck_mw_height="600" alt="" class="fck_mw_center" /&gt;


== Physical Therapy Management (current best evidence)  ==
== Physical Therapy Management (current best evidence)  ==


While there is lack of evidence that discusses specific physical therapy interventions for cellulitis, therapists should be aware of the signs and symptoms in order to refer the patient appropriately. Physical therapists should have awareness of risk factors and various causes of cellulitis, in addition to signs and symptoms.
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There are some modalities that physical therapists can use for a patient with cellulitis. Rest and elevation of the affected limb is important and can help alleviate pain. The application of cool, wet, sterile bandages is also recommended for pain relief, and ice can be used as well. Massage to promote lymphatic drainage, may help prevent cellulitis, particularly when used in conjunction with compression and exercise. However it should not be used during an active cellulitis infection.<ref>University of Maryland Medical Center. http://umm.edu/health/medical/altmed/condition/cellulitis (accessed 25 March 2017).</ref><br>


== Differential Diagnosis  ==
== Differential Diagnosis  ==


Common differential diagnoses for Cellulitis include '''Deep Vein Thrombosis, Dermatitis, and Erythema Migrans'''. A description of these and additional diagnoses are described in Table 1.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Bailey" /&gt;&nbsp;A diagnosis other than Cellulitis can be due to infectious, inflammatory, vascular or neoplastic conditions. These are discussed in Table 2.&lt;span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Raff" /&gt;&nbsp;<br>
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&lt;img src="/images/5/5d/DD_Cellulitis.PNG" _fck_mw_filename="DD Cellulitis.PNG" _fck_mw_location="left" _fck_mw_width="334" _fck_mw_height="710" alt="" class="fck_mw_left" /&gt;&lt;img src="/images/0/02/DD_Cellulitis_2.png" _fck_mw_filename="DD Cellulitis 2.png" _fck_mw_location="center" _fck_mw_width="298" _fck_mw_height="483" alt="" class="fck_mw_center" /&gt;
 
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== Case Reports/ Case Studies  ==
== Case Reports/ Case Studies  ==


add links to case studies here (case studies should be added on new pages using the &lt;a href="Template:Case Study"&gt;case study template&lt;/a&gt;)<br>  
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== Resources <br>  ==
== Resources <br>  ==


<u>Patient Resources:</u>
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American Academy of Dermatology tips for avoiding recurrance of Cellulitis:<br>
 
#Avoid injuring your skin
#Treat wounds right away
#Keep your skin clean and moisturized
#Keep your nails well-manicured
#Do not have blood drawn in an arm that has had cellulitis
#Treat infections promptly
#Treat other medical conditions
#Treat lymphedema
#Lose weight
#Stop Smoking
#If you drink alcohol, drink in moderation
#Check your feet every day to see if you have an injury or infection<br>


&lt;img src="/images/thumb/a/a7/Cellulitis_prevention.JPG/247px-Cellulitis_prevention.JPG" _fck_mw_filename="Cellulitis prevention.JPG" _fck_mw_width="300" _fck_mw_height="200" alt="" /&gt;<ref>Cellulitis [Internet]. Cellulitis | American Academy of Dermatology. [cited 2017Apr4]. Available from: https://www.aad.org/public/diseases/rashes/cellulitis</ref><br>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==


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<u>Healthcare Provider Resources:</u>
 
The following video link by dermatologist Dr. Noah Craft MD, PhD, DTMH discusses Cellulitis from the provider point of view and includes case studies, differential diagnosis, and treatment approaches.
 
https://www.youtube.com/watch?v=ZkntcZt0aho&amp;feature=youtu.be<br>
 
== Recent Related Research (from &lt;a href="http://www.ncbi.nlm.nih.gov/pubmed/"&gt;Pubmed&lt;/a&gt;)  ==
 
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== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


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== References  ==
[[Category:Bellarmine_Student_Project]]
 
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Revision as of 02:16, 11 April 2017

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Kacie McClendon, Elaine Lonnemann, Erica Shelley, Kim Jackson, Lucinda hampton, Fasuba Ayobami, 127.0.0.1, Vidya Acharya, Claire Knott, Evan Thomas, WikiSysop and Karen Wilson  

Definition/Description[edit | edit source]

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Prevalence[edit | edit source]

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Characteristics/Clinical Presentation[edit | edit source]

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Associated Co-morbidities[edit | edit source]

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Medications[edit | edit source]

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Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]

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Etiology/Causes[edit | edit source]

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Systemic Involvement[edit | edit source]

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Medical Management (current best evidence)[edit | edit source]

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Physical Therapy Management (current best evidence)[edit | edit source]

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Differential Diagnosis[edit | edit source]

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Case Reports/ Case Studies[edit | edit source]

add links to case studies here (case studies should be added on new pages using the case study template)

Resources
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add appropriate resources here

Recent Related Research (from Pubmed)[edit | edit source]

see tutorial on Adding PubMed Feed

Extension:RSS -- Error: Not a valid URL: addfeedhere|charset=UTF-8|short|max=10

References[edit | edit source]

see adding references tutorial.


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