Management of cellulitis and erysipelas

For management of periorbital (preseptal) or orbital (postseptal) cellulitis, see Approach to managing periorbital (preseptal) cellulitis or Approach to managing orbital (postseptal) cellulitis.

For additional considerations that may affect management of patients with cellulitis or erysipelas, see Assessment of cellulitis and erysipelas and Aetiology of cellulitis and erysipelas.

Rest and elevation of the affected area improves symptomsStevens, 2014. Address contributing factors such as oedema (eg due to lymphoedema or cardiac failure) or venous insufficiency. If the skin is not intact, or cellulitis is associated with an ulcer, see Ulcer and Wound Management Guideline for advice on wound management and choice of dressings.

Oral antibiotic therapy is adequate for most patients with cellulitis or erysipelas without systemic features who are able to tolerate and absorb oral therapy.

Initial intravenous therapy targeting beta-haemolytic streptococci and Staphylococcus aureus is recommended for patients:

  • unable to tolerate and absorb oral therapy
  • with extensive erythema
  • with systemic features of infection (including chills, rigors or fever [38°C or higher]).

Intravenous therapy may also be required for patients with immune compromise or comorbidities that increase the risk of rapid disease progression (eg diabetes), even if they do not have systemic features of infection.

Piperacillin-tazobactam, ceftriaxone and cefotaxime have a broad spectrum of activity that is not required for cellulitis that is likely to be caused by streptococci or staphylococci.

Patients with cellulitis associated with hypotension, septic shock, severe pain, or rapid progression of systemic features or erythema require broader-spectrum intravenous therapy.

The principles of managing cellulitis or erysipelas in people who inject drugs are the same as for any other patient. However, involvement of additional specialities including addiction medicine and psychiatry may be required. Nonjudgemental harm reduction advice may reduce the risk of acquiring serious infections. For printable patient information on harm reduction strategies to minimise risk of infection, see Harm reduction advice to reduce risk of infection for people who inject or smoke drugs. For a more comprehensive patient information sheet on harm reduction advice for people who use substances, see How to get help and reduce harms from alcohol and other drugs or gambling - patient information. For other harm reduction strategies, see Harm reduction in substance use and addictive behaviours.