Clinical Review

Diagnosis and management of cellulitis

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e4955 (Published 07 August 2012) Cite this as: BMJ 2012;345:e4955

This article has a correction. Please see:

  1. Gokulan Phoenix, core surgical trainee year 1 (London Deanery)1,
  2. Saroj Das, consultant vascular surgeon2,
  3. Meera Joshi, core surgical trainee year 1 (Oxford Deanery)3
  1. 1Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH
  2. 2Department of General Surgery, the Hillingdon Hospitals, London
  3. 3Department of General Surgery, Wexham Park Hospital, Oxford
  1. Correspondence to: G Phoenix gokulan.phoenix{at}nhs.net
  • Accepted 12 July 2012

Summary points

  • Cellulitis episodes in the United States, the United Kingdom, and Australia have risen over the past decade, with an increase in community acquired meticillin resistant Staphylococcus aureus (CA-MRSA) cases of cellulitis in the US, and to a lesser extent the UK and Australia. Antibiotic resistant strains of CA-MRSA are already emerging

  • Diagnosis is based on clinical findings with investigations lending weight to confirm or refute diagnosis

  • Existing guidelines need revision, taking into consideration CA-MRSA and other emerging strains as well as using new clinical classification systems such as the Dundee criteria

  • Use outpatient parenteral antibiotic therapy if available

  • More randomised control trials assessing the management of predisposing factors and long term therapy for recurrent cellulitis are required

Cellulitis is an acute, spreading, pyogenic inflammation of the lower dermis and associated subcutaneous tissue. It is a skin and soft tissue infection that results in high morbidity and severe financial costs to healthcare providers worldwide. Cellulitis is managed by several clinical specialists including primary care physicians, surgeons, general medics, and dermatologists. We assess the most recent evidence in the diagnosis and management of cellulitis.

Sources and selection criteria

We searched PubMed and the Cochrane library for recent and clinically relevant cohort studies and randomised controlled trials on cellulitis, using the search terms “cellulitis”, “erysipelas”, “diagnosis”, “investigation”, “recurrence”, “complications” and “management”. For position statements and guidelines we consulted the British Lymphology Society (BLS), National Health Service Clinical Knowledge Summaries (CKS), Clinical Resource Efficiency Support Team (CREST), and Infectious Disease Society of America (IDSA).

What is the extent of the problem?

In 2008-9 there were 82 113 hospital admissions in England and Wales lasting a mean length of 7.2 days1; an estimated £133m (€170m; $209m) was spent on bed stay alone.2 Cellulitis accounted for 1.6% of emergency hospital admissions during 2008-9.3

In Australia, hospital admissions for cellulitis have risen to 11.5 people …

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