Cellulitis

Adviser
dr. Amru Sungkar, Sp.B, Sp.BP-RE
 Phoenix et al (2012)
• Cellulitis is an acute, spreading,
pyogenic inflammation of the lower
dermis and associated subcutaneous
tissue.
Wingfield, Carrie (2009)

Definition • Cellulitis is classed as an acute

spreading bacterial infection and
inflammation of the connective tissue,
dermis and subcutaneous layers of the
skin.
• The most common infective organisms
in adults are streptococci (esp. Strep.
pyogenes) and Staph. aureus3
 In the US more than 600.000 hospitalizations
were recorded in 20104

Some American studies rated 24.6 cases per

1000 person/year might be affected with
cellulitis
Epidemiology Children are afected at a very young age: 7-10
months, and a history of infections is often
reported in the weeks before, especially otitis
media3

White people > black people3, male = female3

Predisposing
Factors4
 Adults : lower extremities4
Predilection
Children: head and neck4
 S. Aureus more likely
Most community
to be bullous and
cellulitis caused by S.
associated w/
pyogenes and S.
concomitant skin
Aureus7
wound7
Aetiology
S. Pyogenes can
involve lymphatics ->
skin become tense,
thickened -> peau d’
orange appearance7
 Human skin serves first
line of defence againts
microbial infection
(physical barrier)

Infecting organism
Pathogenesis penetrated the
8
integumentary barrier

Skin and Soft Tissue

(SSTI) damage and
inflammatory response
 3 Steps Development of SSTI6

Bacterial Invasion of
Elaboration of
adherence to tissue & evasion
toxins
host cells of host defences

Bacterial toxins are the most potent and responsible

for clinical disease
 Bacterial
toxins

endotoxin exotoxin

Lipopolysaccharidae
Actively secreted
chain found in
proteins that cause
bacterial gram
tissue damage
negative cell wall
 Microbial
Infection induce host invasion/tissue
response: damage changes
inflammation vascular tone -> blood
flow ↑

Cell phagocytize
Extravasation of
Inflammation plasma protein &
destroy foreign
6 leukocytes
matter, dead tissue or
microbes

Certain pyrogenic
cytokines or exotoxin
cause the febrile
response
 Cardinal Ancillary systemic
manifestations: signs: fever,
warmth, erythema, hypotension,
Clinical edema, pain and tachycardia
manifestations dysfunction

of The release of
inflammation6 cytokines mediated
by normal immune
cell function/toxin
stimulation
Cardinal signs of inflammation

Area of erythema expand, borders are ill defined

Systemic symptoms: fever w/ chills, malaise precede the eruption

Heavy pain, higher peripheral sensibility, frequent paraesthesia

Hypoaesthesia : alarming sign of deeper nerve involvement

 erisipelas: superficial
dermis infection, bright red Varicose eczema which is
swelling patch, sharply often bilateral with
demarcated from adjacent crusting, scaling and itch or
unaffected skin, “step sign” other lower leg eczema3
(raised border)4
Differential
diagnosis
Acute liposclerosis which
DVT with pain and swelling
may have pain, redness and
without significant
swelling in the absence of
erythema3
significant systemic upset3
 Laboratoric examination (IDSA
recommend)10
• Cultures of blood and cutaneous aspirates,
biopsies
• Blood examination : leukocytosis/netrophilia

Additional Radiologic examination3

examination
• Not routinely recommended

Histopatologic examination9

• Seldom used, can show coexisting disease

Management of SSTIs
IDSA Guideline (2014)
Prognosis7
Chronic illness and bad
nutritional status: risk
factors for complications
and mortality
(limmunodeficiency
Usually good
condition: HIV or
consequence of systemic
treatment, such as
corticosteroids, and
cytostatics)

Patients with diabetes

mellitus, chronic renal
failure on haemodialysis,
A common factor
or who use illicit
predisposing to recurrent
parenteral drugs may
cellulitis: tinea pedis
develop recurrent
staphylococcal skin
infections.
 Patient identity

Name : Mrs. W
Age : 50 years old
Job : Chef
Address : Kalimantan
Date of examination : November 4th, 2015
Reg numb : 0131xxxx
Chief Complaint

Both legs were swollen and red

 Present Illness (alloanamnesis) November 4th, 2015

1 month before 3 weeks before 1 week before 5 days before

• Appears boil in the • Appears boil in the • Patient’s limb was • The swollen was
right hand, after right leg and the swollen bigger than before,
several days appears patient also • Not yet red and feels began to appear
eye ulcer and the complained of pain hot eritema and feels
patient massaged it in the stomach hot
so the pus could • The patient went to • Patient transferred
come out Pangkalan Bun to Moewardi
Hospital Hospital with
• In the hospital, her suspected DVT
blood sugar was 345 • Cardiology
mg/dl, blood department denied
pressure was it, so the patient
170/110mmHg consulted to
• The patient was Dermatovenerology
treated by department with
neurologist and suspected Cellulitis
internist
Past illness
Same illness : denied
DM : denied, but the bloo sugar
was 345 mg/dl, HbA1c was
7,1%
HT : (+)
Food and drug allergy : denied

Family history
Same illness : denied
Food and drug allergy : denied
DM : denied
HT : denied
 Physical examination
 General state :Somnolent
 Vital sign : BP: 120/80 mmHg, HR: 88 x/11, RR : 35x/1’ , T : afebrile
 Cephal : normal
 Neck : normal
 Eyes : normal
 Abdomen : normal
 Thorax : normal
 Back : normal
 Supor Extremity : normal
 Infor extremity : see dermatology status
 Genitalia : normal
Dermatology status erythema

Right leg region warm

edema

pain

Borders are
diffuse and ill
defined

Borders
aren’t raised

Yellow Peau d’
Crusted orange
Dermatology status erythema

Left leg region warm

edema

pain

Borders are
diffuse and ill
defined

Borders
aren’t raised

Peau d’
orange
Differential diagnosis

Cellulitis
Erysipelas
Laboratory examination
Gram staining: PMN 0-1/LPB
coccus gram (+) 50-70/LPB

Blood: Leucocyte : 14.7 (↑)

Pus and Blood Culture

Working diagnosis

Cellulitis
 Treatment

Non medical :
Leg elevation 300 to reduce edema
Keep hygiene and immune status

Medical :
Compress with NaCl 0.9% 2x15’
Topical: antibiotic zalf (fusidic acid cream 2%)
twice/day
Azytromycin 500mg / day Per Oral
 Prognosis
Ad vitam : dubia
Ad sanam : dubia
Ad fungsionam : dubia
Ad cosmeticam : dubia
 1. Phoenix et al. Diagnosis and Management of Cellulitis.

Referrences British Medical Journal. 2012; 1-8.

2. Wingfield, Carrie. Diagnosing and Managing Lower Limb
Cellulitis: A Dermatology Persperctive. Wounds UK;
2009(5) No 2.
3. CREST (Clinical Resource Efficiency Support Team)
Guidelines on The Management of Cellulitis in Adults.
2005; 1-31.
4. Atzorl, et al. New Trends in Cellulitis. Department of
Dermatology of European Medical Journal. 2013; 64-76.
5. Hadzovic-Cengic, et al. Cellulitis – Epidemiological and
Clinical Characteristics. Clinic for Infectious Diseases,
Clinical Center of University of Sarajevo, Bosnia and
Herzegovina. 2012; 1-3
 6. Ki V, Rotsein C. Bacterial Skin and Soft Tissue Infection in Adults : A
Review of Their Epidemiology, Pathogenesis, Diagnosis, Treatment, and

Referrences Site of Care. The 2007 CJIDMM Trainee Review Article Award. 2008;
173-184.
7. DiNubile MJ, Lipsky BA. Complicated Infection of Skin and Skin
Structures: When The Infection is More Than Skin Deep. Journal of
Antimicrobial Chemotherapy. 2004; ii37-ii50.
8. Blauvelt A. Cellulitis. Dalam: Wolff K, Goldsmith LA, Katz
SI,Gilchrest BA. Paller AS, Leffell DJ, penyunting. Fitzpatrick’s
Dermatology in General Medicine. Edisi ke-7. New York: McGraw Hill
Companies; 2008. h. 1721, 1727.
9. Stevens DL et al. Practice Guidelines for the Diagnosis and
Management of Skin and Soft Tissue Infection: 2014 Update by The
Infectious Disease Society of America. Clinical Infectious Disease
Advance Acess. 2014; 1-4
10. Keeley, et al. Management Cellulitis in Lymphoedema. The
Lymphoedema Support Network. 2010;1-10
THANK YOU