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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.77 no.5 Rio de Janeiro Sept./Oct. 2002
Clinical experience assessing 284 cases of erisipela*
Carlos Henrique de A. BernardesI; João Carlos de Aguiar AugustoII; Larissa Torres Cardoso LopesIII; Karina Torres CardosoIII; Jaqueline Rodrigues dos SantosIII; Lusimeire Máximo dos SantosIII
Professor of Vascular Surgery at the Santos School of Medicine. Head of the
Vascular Surgery Service of the Santa Casa de Misericórdia de Santos
IIAssistant at the Vascular Surgery Service of the Santa Casa de Misericórdia de Santos
IIIUndergraduate at the Santos School of Medicine
This study concerns Erysipelas disease in Brazil and is also a warning regarding the importance of preventing its recurrence, which may lead to a clinical picture of elephantiasis and consequent impairment in the domestic, social and professional life of the patient. A retrospective analysis was performed of 284 cases of erysipelas in the period from 1995 to 1996, considering the following features: sex, age, related mapping of the injured tissue, systemic and local predisposition, means of infection, medical treatment, concurrent disease and eventual need for hospitalization. The results showed that males and obese individuals are the most likely to be affected by the disease and especially those from 60 to 70 years old. The inferior members were the most affected by the disease. Skin lesions due to tinea pedis were the main entry site of the bacterial agent. Hospitalization was necessary when the patient presented necrotic lesions. Penicillin G benzathine and crystalline penicillin were the medicines of choice and side effects were not observed in the majority of cases.
Key words: Erysipelas; Streptococcus
Erysipelas is a superficial cellulitis with intense involvement of the subjacent lymphatic plexus and is characterized by erythematous plaque accompanied by pain and edema. It also presents raised borders and induration that confers an orange-peel aspect to the skin, according to the observations of Tanaka. These lesions expand outwards, become hot and have a sharply defined margin, two or three days after onset of the general symptoms, which include a prodromal period, in that there is an abrupt elevation of the temperature reaching 39°C or 40°C with chills, nausea and intense indisposition.
The most common etiological agent of erysipelas is group A b-hemolytic Streptococcus (rarely groups C or G and in new born infants group B),2 infection by Staphylococcus aureus may also be observed.
It occurs in all age groups, though with a peak between 60 and 80 years. The inferior members are most frequently involved, followed by the face and superior members. It is also more frequent in female patients. In most cases there is a very well-defined entry site, such as ulcers, traumas, superficial mycoses, insect bites and inadequately treated wounds.
Diagnosis is essentially clinical, since isolation of the agent is rarely acheived, probably due to its scarce presence or to the complex requirements of the culture medium.
Penicillin is indicated for most cases of erysipelas, but erythromycin can be used when the patient presents an allergic reaction to this type of medication.
The most frequent complications are bullous necrotizing erysipelas, abscess and superficial and profound thrombophlebitis.
An increase in the attendance of patients with erysipelas at the emergency and first aid services of hospitals1,3 motivated this study, with the objective of clarifying the correct diagnosis and appropriate treatment of these patients.
This study is a retrospective analysis of 284 cases of erysipelas treated in the Vascular Surgery Service of Santa Casa de Misericórdia de Santos during the period from 1995 to 1996.
The diagnosis of erysipelas was confirmed clinically, by the presence of plaque with four classic inflammatory signs and sharply defined borders, accompanied by high fever, chills and adenomegaly.
The following factors were analyzed: sex, age, related mapping of the injured tissue, local factors and systemic predisposing factors, entry site, treatment, complications and eventual need for hospitalization.
Of the 284 patients studied, 130 (45%) were female, and 154 (55%) male. The disease involved patients in the 13 to 87-year-old age group, with a mean age in this study of 54 years.
All 284 patients presented erysipelas in the inferior members, although one also presented the disease in the right buttock. Of these cases, 120 (43%) presented involvement of the left inferior member, 113 (40%) of the right inferior member and 50 (17%) of both. It was also observed that 73 (25%) cases had undergone more than one episode of erysipelas.
Furthermore, 221 (78%) patients had some predisposing factor. These were classified into local and systemic factors, with 111 (50%) and 110 (50%) cases respectively.
Regarding local predisposing factors (111 cases), the authors observed only one (1%) case of chronic lymphangitis, 62 (56%) venous insufficiency, 38 (34%) prior history of surgery for varicose veins, and 10 (9%) previous heart surgery with saphenectomy.
Of the predisposing systemic factors, there were 50 (17%) cases of obesity, 20 (10%) of diabetes mellitus and 40 (14%) with arterial hypertension.
The entry site was determined in 75 (26%) patients, of which there was one case of ulcer in the right inferior member, one of trauma in the right foot and 73 with clinical suspicion of dermatophytosis, though without mycological exam.
The complication detected was bullous necrotizing erysipelas, with 15 (5%) cases, of which one was later submitted to a skin graft.
The antibiotic therapy administered to 237 (83.5%) patients used penicillin with erythromycin in 42 (15%) and penicillin with other antimicrobial agents in five (1.5%); diosmine was used as an auxiliary to the treatment in 129 (45%) cases.
A total of 23 (8%) cases required hospitalization.
In this study the authors detected a slight male bias (55%), which differs from the work of Chartier and Grosshans.
With regard to age, there was a prevalence in the age group of 60 to 70 years old, and the mean age was 54 years, these findings corroborate the literature.4,5
The site most involved by erysipelas according to the literature 16 consulted was the inferior members, as was found in this study (approximately 90%). According to Ronnen et al. and Dompmartin, the greater concern for aesthetics and appropriate facial hygiene could be responsible for the reduced incidence in the face, which was common in previous times.
In addition, regarding the recurrence of the disease, this was observed in 25% of the cases, which was compatible with the data of Sjöblom et al. (29%) and Cricky et al. (23%).
Lotem et al. report a case of a 75-year-old woman who, after 40 years of recurrent erysipelas in the same leg, developed multiple (n = 23) basal cell carcinomas, even in the absence of a prior history of radiation or other carcinogenic factors. On the other hand, radiotherapy can favor the recurrence of erysipelas. Immunological deficiency and venous insufficiency are important predisposing factors in this infection.
The predisposing factors can be divided into local and systemic, the former represented mainly by venous insufficiency and less frequently by chronic lymphangitis. In the present study the authors also considered prior surgery of varicose veins as a local factor since following this operation edema, fissures and infection can occur in the lymphatic system. Another local factor was heart surgery with excision of a saphenous vein for myocardial revascularization,2which can harm the neighboring lymphatics of the vein and thereby rendering the inferior member more susceptible to erysipelas. Among the general predisposing factors are diabetes, obesity, arterial hypertension, use of tobacco and alcoholism. The authors consider arterial hypertension to be an aggravating factor due to involvement of the arteriole-capillary-vein territory, with obstruction of minor vessels, harming the venous drainage and predisposing the individual to edema and infection.8
In this study it was observed that 78% of the patients presented either local or systemic predisposing factors, a fact also observed by David et al. (65%). As for the local predisposing factors, a prevalence of venous inadequacy was verified (56%), which is in accordance with the findings of other authors.12In addition 38 (34%) patients had undergone prior surgery of varicose veins and 10 (9%) heart surgery.
Regarding the predisposing systemic factors, 50 cases (17%) of obesity were identified in the literature, furthermore 10% of cases presented diabetes mellitus, while David et al. found 9% and Ronnom et al., 8.3%.
The authors consider the occurrence of 40 cases of arterial hypertension (14%), to be interesting as this contributes to the systemic predisposing factors.
Recurrent episodes of erysipelas can occur with relative frequency and most of the time this is due to a lack of hygiene on behalf of the patient while treating an interdigital mycosis or immunological predisposition to the disease.13,14 In cases of recurrence, secondary infection by Staphylococcus aureus should be tested for and eliminated. Erysipelas should be treated with systemic antibiotic therapy to prevent complications.15
Cricky et al., in their study found interdigital mycosis in 26% of the cases - the present authors observed 27.4% - characterizing this fact as the entry site of the disease.
In relation to antibiotic therapy, in most of the cases (n = 237, 83.5%) penicillin G benzathine or crystalline penicillin was used, as reported in the literature revised by the authors, however it is worth underscoring that in cases of allergy to penicillin, erythromycin was used in 42 (15%) cases. Diosmine was also used as a supporting therapy in 129 (45%) patients and it is believed that the mechanism by which it improves the picture lies in its phlebotonic and lymphotonic action, by increasing the lymphatic drainage, with consequent decrease in the edema.
All 23 (8%) patients with toxemia and anorexia required hospitalization for their clinical treatment, complemented with rest and compresses with topical antiseptics.
In this clinical study, there was a male sex bias in the disease and the 60 to 70-year-old age group was most affected. Obese individuals were also shown to be more predisposed to contract erysipelas. The inferior members were the most frequently involved and lesions due to tinea pedis were the main entry site for the causal agent of the disease. The most serious complication of erysipelas was necrotizing blisters, which sometimes required hospitalization. The treatment most used in this study included crystalline and G benzathine penicillin.
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17. Dompmartin, A. et al., Sweet syndrome associated with acute wyelogenus leukemia. Atypical from simulating facial erysipelas. Int. J. Dermatol., 1991; 30(9): 644-7. [ Links ]
Dr. Carlos Henrique de Alvarenga Bernardes
Rua Luiz Suplicy, 73 / Conj. 1 - Gonzaga
Santos SP 11055-330
Tel.: (13) 3234-9532/3232-3587
Received in July,
21th of 1998.
Approved by the Consultive Council and accepted for publication in March, 6th of 2001.
*Work done at "Serviço de Cirurgia Vascular da Santa Casa de Misericórdia de Santos - Faculdade de Ciências Médicas de Santos"