18 Nursing Times 03.07.12 / Vol 108 No 27 / www.nursingtimes.

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Nursing Practice
Discussion
Cellulitis
Author Carrie Wingeld is nurse
consultant dermatology, Norfolk and
Norwich University Hospital, and associate
lecturer, University of East Anglia.
Abstract Wingeld C (2012) Diagnosing
and managing lower limb cellulitis. Nursing
Times; 108: 27, 18-21.
The diagnosis of lower limb cellulitis
requires careful and structured
assessment. This article looks at the
assessment, diagnosis and management
of cellulitis, focusing on the lower limb.
Assessment should include good skin
examination as active skin disease, such as
venous stasis eczema and athletes foot
(tinea pedis), is often overlooked as a
primary cause of lower limb cellulitis and
recurrent episodes.
C
ellulitis is classed as an acute
spreading bacterial infection
and inammation of the con-
nective tissue, dermis and sub-
cutaneous layers of the skin. It is charac-
terised with redness (erythema), warmth,
swelling and pain (Fig 1). Localised tender-
ness is a diagnostic feature and can be
accompanied by pyrexia and general
malaise (Gunderson, 2011). It is an oppor-
tunistic infection, commonly occurring
through breaks in the skin. The term ery-
sipelas has been used to describe a more
supercial infection of the dermis and
upper subcutaneous layer of the skin;
often the two presentations coexist.
There are several predisposing condi-
tions and risk factors for cellulitis (Box 1);
these should be looked for in the clinical
diagnosis to aid primary and secondary
treatment decisions, and make patients
aware of their potential risk of further
episodes.
Keywords: Cellulitis/Lower limb
cellulitis/Diferential diagnosis

This article has been double-blind

peer reviewed
5 key
points
1
It is important
to recognise
diagnostic features
of clinical
presentation to
ensure accurate
diagnosis and
correct
management
of cellulitis
2
Assessment of
the lower limb
needs thorough
skin examination to
exclude or diagnose
active skin disease
3
Misdiagnosis is
common;
practitioners
should be aware
of potential
diferential
diagnosis and
appropriate
investigations
4
Ongoing
patient advice
and education is
key as patients
may experience
further episodes;
risk factors need to
be highlighted
5
Cellulitis
management
should be
considered using a
multidisciplinary
approach
Identied pathogens usually involve
Staphylococcus aureus and Streptococcus pyo-
genes; other less common ones also exist.
Published data on incidence is unreliable
because of the variability and often incon-
sistent clinical practice in managing this
condition (Clinical Resource Efciency
Support Team, 2005; Kilburn et al, 2003).
There is no statistically signicant differ-
ence in the incidence of cellulitis in men
and women (McNamara et al, 2007).
Studies have found a higher incidence of
cellulitis in general among people over 45
years (Bjrnsdttir et al, 2005).
Diagnosing cellulitis
Presentation of lower limb cellulitis
Cellulitis commonly presents locally as a
well demarcated area of redness (ery-
thema); associated tenderness, warmth
and swelling are simple clinical criteria for
diagnosis. If there is no increased warmth
over the skin it is unlikely to be cellulitis.
Sometimes blisters are present or super-
cial haemorrhage and necrosis. Lymph
glands may be enlarged and palpable.
The leg is the most common presenting
site and in most cases unilateral; bilateral
cellulitis is extremely rare (CREST 2005,
Quartey-Papao 1999). In the absence of
common clinical features, differential
diagnoses must be considered before
starting treatment (Box 2).
Medical history
Taking a thorough comprehensive medical
history is key to diagnosing cellulitis and
determining risk factors and comorbidi-
ties. Onset of symptoms should be dened
together with the original starting point of
inammation. History of any trauma to the
area, even minor, should be ascertained and
In this article...
Diagnosing, assessing and treating cellulitis
The importance of diferential diagnosis
Benets of a dedicated cellulitis service
Nurses need to use the best available evidence to assess, diagnose and
treat cellulitis, thereby ensuring their patients receive optimal care
Diagnosing and managing
lower limb cellulitis
www.nursingtimes.net / Vol 108 No 27 / Nursing Times 03.07.12 19
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useful step-by-step guide on diagnosing,
assessing and managing cellulitis (see
tinyurl.com/Wingeld-cellulitis).
Referring to acute care
Hospital admission should be considered
if symptoms are severe and worsening,
including extensive skin involvement and
marked spread, or systemic signs are evi-
dent. Symptoms may include:
Unresolving pyrexia;
Nausea and vomiting;
Comorbidities that may complicate or
delay healing;
The very young (children under one
year) and older and frail people;
Lymphoedema;
Facial cellulitis;
Periorbital cellulitis (refer to
ophthalmologist).
Diagnostic investigations
Patients usually respond well to standard
antibiotic regimens but if there is no
response to the initial choice of antibiotic,
the organism may be resistant to the drug
or a combination of antibiotics may be
required. If any pustules, crusts or ero-
sions are present, a swab can be taken for
culture, particularly if rst-line oral anti-
biotics have failed.
A complete blood count is likely to show
leukocytosis (raised white cell count).
Blood cultures may be useful if a patient
has a high fever or is otherwise very unwell.
The erythrocyte sedimentation rate and
C-reactive protein level are frequently ele-
vated, especially in patients with severe
infection. Baseline systemic observations
including temperature, pulse, blood pres-
sure and respirations should be recorded.
Differential diagnosis
Further investigations may become neces-
sary if differential diagnosis is suspected,
for example, deep vein thrombosis. Cox
(2002) and Quartey-Papao (1999)
acknowledged problems with the inappro-
priate diagnosis of cellulitis; for example,
it can be confused with venous stasis
circumstances identied as this may help
decide on antibiotic management. Injury, if
any, may have occurred several days before
symptoms, but patients may not relate the
injury to the onset of cellulitis. Cuts and
wounds obtained via water environments
such as lakes, streams, sea and ponds
(brackish water) may be contaminated with
bacteria. Water-borne bacteria should be
considered if patients fail to respond to
conventional antibiotic treatments.
Fever, malaise, nausea, shivering and
rigors may accompany or precede skin
changes. Lymphangitis (infection of
lymph vessels) can also present in more
severe cases, appearing as a red line origi-
nating from the cellulitis and leading to
tender swollen lymph glands draining the
affected area (for example, in the groin
with leg cellulitis).
Progression of symptoms, especially if
this is rapid, can be a sign of a more acute
and deeper infection such as necrotising
fasciitis, and should be fast-tracked to
acute care. Other systemic symptoms such
as tachycardia and increased respirations
may indicate sepsis and should be care-
fully monitored. Cellulitis that has spread
to an adjacent structure (such as osteomy-
elitis) or through the blood (bacteraemia)
is a serious cause for concern and requires
immediate hospital admission. Patients
with mild or moderate cellulitis without
systemic symptoms should be managed in
primary care. Wingeld (2009) contains a
BOX 1. RISK FACTORS FOR
CELLULITIS
Diabetes
Lymphoedema/chronic oedema,
primary or secondary
Insect bites
Skin trauma/ulcers
Blistering disorders bullous
pemphigoid, bullous impetigo
Animal bites
Skin rash venous stasis eczema,
athletes foot (tinea pedis)
Dry skin
Pregnancy
Obesity
Burns
Recent surgery
Immunodeciency (cancer, kidney and
liver disease, peripheral vascular disease)
Immunosuppressive drugs
Intravenous drug misuse
Alcoholism
BOX 2. DIFFERENTIAL
DIAGNOSES OF CELLULITIS
On the legs, conditions that commonly
mimic cellulitis include:
Venous stasis eczema (but this is
usually bilateral with crusting, scaling
and itch)
Deep vein thrombosis (but this does
not usually cause signicant erythema)
Less common conditions that may
initially present with similar signs and
symptoms to cellulitis include:
Necrotising fasciitis
Gangrene
Acute gout
Adverse drug reactions
Metastatic cancer (carcinoma
erysipeloides)
Contact dermatitis
Erythema nodosum
Panniculitis
Lipodermatosclerosis
Vasculitis
Thrombophlebitis
eczema (Quartey-Papao, 1999) (Fig 2).
Table 1 illustrates the clinical difference
between the two conditions.
If skin disorders such as venous stasis
eczema are diagnosed and treated appro-
priately, there is potential to reduce the
risk of cellulitis and recurrent episodes,
which can lead to chronic oedema and
lymphoedema (Wingeld, 2009).
Fig 2. Varicose eczema of the leg
associated with venous insufciency
Fig 1. Cellulitis of the foot
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Nursing Practice
Discussion
often referred to dermatology, mainly
because of recurrent episodes of cellulitis,
discomfort, poor lymphorrhoea control
and impact on resources. It is crucial not to
dismiss this as untreatable to do so is
arguably negligent. Wet, leaking, smelly
bandages impact signicantly on patients
quality of life and safety. Quality of life and
psychological aspects should be included
in any chronic oedema assessment.
Control of lymphorrhoea can realisti-
cally only be achieved with the correct lym-
phoedema treatment, which includes cor-
rect bandaging and skincare. The use of
absorbent dressings removes moisture
from the wound/skin; dressings that con-
tain gel-forming agents that lock the
uid away should also be considered
(Thomas, 2008). The uid-handling capa-
bility of these dressings, however, will not
solve the problem; practitioners should not
continuously add to the dressing to absorb
leakage, especially if there is a wound/ulcer.
It is vital that absorbent dressings are con-
sidered as primary wound choice in cases
of lymphorrhoea and associated wounds
but their frequency of change should be
closely monitored. Good attention to skin-
care should also be considered a bench-
mark in these patients (Beldon, 2009).
Compression therapy in managing
lymphorrhoea is paramount if patient cir-
culation and cardiac history allows,
together with elevation and exercise.
Applying compression to the lower limb
aids drainage of excess uid back in to the
capillaries by reducing the capillary pres-
sure (Anderson, 2006).
There is little evidence in the literature
on the use of compression during an acute
episode of cellulitis; individual presenta-
tions and patients medical history need to
form part of the decision. Swelling caused
by infection increases pressure in the tis-
sues and leads to higher pressures than
normal under compression. This could
impair circulation, leading to tissue
necrosis and/or distal ischaemia, espe-
cially where tissue oxygenation has been
borderline under compression.
These potential risks should lead to
advice to discontinue or reduce the level of
compression during cellulitis episodes.
From personal clinical experience the
majority of patients nd cellulitis too
painful to tolerate compression until
symptoms subside and, in most cases,
would discontinue as recommended by
CREST (2005). If a decision is made to con-
tinue compression during cellulitis,
patients need close monitoring until the
swelling and cellulitis is under control.
A cellulitis service
The CREST (2005) guidelines proposed
increasing awareness in both primary
and acute care of the need to improve cel-
lulitis diagnosis and management. They
advocated a dedicated cellulitis service to
reduce delays in diagnosis, cut the costs
and administration of inappropriate treat-
ment and increase the day-to-day manage-
ment of cellulitis and education about the
condition. The multidisciplinary approach
ideally should include:
Nurse (community or hospital);
GP;
Pharmacist;
Microbiologist;
Specialist services dermatology;
Physiotherapist;
Lymphoedema services.
These recommendations have been put
into practice in some hospital trusts. The
Norfolk and Norwich University Hospital
shows an excellent example of this initia-
tive and offers a same-day referral cellu-
litis clinic in the dermatology outpatient
department (Wingeld, 2008). GPs can
refer patients with lower limb cellulitis to
this clinic, where they receive a thorough
assessment including diagnosis, treat-
ment and investigation of any differential
diagnosis or coexisting skin disease.
Patients are seen by a specialist team
and booked into a 90-minute assessment
slot. Suitable patients are treated with
ceftriaxone intravenous (IV) therapy, a
once-a-day antibiotic IV treatment admin-
stered over a three-day period. After
receiving their rst administration in
clinic they are discharged with an IV can-
nula in situ and receive their next two
doses at home from the community IV
team. On day four they return to the clinic
for review where they are stepped down to
oral antibiotics. This has produced a sig-
nicant saving on bed days, offset against
the cost of outpatient treatment. In recog-
nition of this service innovation, the clinic
received the Health Enterprise East Inno-
vation Award in 2008.
The benets of the service are:
A faster pathway;
If patients have pre-existing oedema,
practitioners should consider aftercare of
Doppler ultrasound investigations and
compression hosiery (Wingeld, 2008).
Leg elevation and exercise can improve
venous return and reduce venous pressure
and this may help to improve the skin.
However, there is no evidence on the bene-
ts of these interventions (Dufll, 2008;
Barron et al, 2007).
Venous stasis eczema (varicose eczema)
This common inammatory dermatosis
commonly affects the lower limbs and often
coexists with varicose veins. Clinical signs
include inamed red eczematous skin, itch,
scaling, sometimes weeping crusting skin,
pigmentation (haemosiderin deposit),
hardened skin, tight red/brown skin/tissues
(lipodermatosclerosis vulnerable to ulcer-
ation) and atrophy blanching.
Treatment usually consists of topical
corticosteroids and emollient therapy. A
potent steroid for a short time can be more
steroid-sparing than a milder potency for a
longer period (Davis, 2001). Emollients and
paste bandages are appropriate therapies.
Secondary infection can present in
venous stasis eczema. Clinical signs include
increased spread of eczema, itching, ery-
thema, weeping and yellow crusting, and
may require systemic antibiotics;
switching to an antimicrobial emollient
may be useful if infection is diagnosed.
Tinea pedis (athletes foot)
Tinea pedis is a curable dermatological
primary cause of recurrent lower leg cellu-
litis (Fig 3) but is rarely diagnosed in clin-
ical areas other than dermatology (Pierce
and Daugird, 1992).
Clinical presentation includes scaling,
maceration, ssuring and erythema in the
interdigital area. Treatment and diagnosis
of tinea pedis can potentially reduce subse-
quent recurrent cellulitis. Treatment usu-
ally involves administering topical anti-
fungals such as terbinane for two weeks.
If unsuccessful, practitioners should con-
sider taking skin scrapings for mycology
and systemic therapy may be indicated.
Lymphorrhoea
Patients with lymphorrhoea (poorly con-
trolled weeping of lymph from the skin
surface), which is commonly associated
with chronic oedema/lymphoedema are at
increased risk of cellulitis. Lymphorrhoea
quickly saturates dressings, clothes and
footwear, increasing the risk of infection/
cellulitis through contamination and mac-
eration of skin (Mortimer, 1995).
Patients with wet or leaky legs are
Fig 3. Tinea pedis
www.nursingtimes.net / Vol 108 No 27 / Nursing Times 03.07.12 21
Less pressure on resources;
Reduced waiting lists helping to
achieve the four-hour wait target in
accident and emergency;
Early discharge/preventing admission;
Patients are not exposed to hospital-
acquired infections;
Care in the community, with patients
remaining closer to home;
Prevention of recurrent episodes of
cellulitis.
Studies have supported this change of
clinical pathway and management of lower
limb cellulitis. Seaton et al (2005) recog-
nised high standards in nurse-led home IV
services using ceftriaxone. They concluded
that care is not compromised and the need
for medical review is reduced. Corwin et al
(2005) said home IV treatment is as effec-
tive as hospital inpatient treatment and is
more acceptable to patients.
Patient education
Depending on the location of the affected
area, patients may need to decrease phys-
ical activity and elevate the extremity, if
possible. They may take over-the-counter
pain medication such as ibuprofen or
paracetamol if there are no contraindica-
tions. Where patients are started on oral
antibiotics, review should take place after
5-7 days with the proviso that they contact
the surgery or outpatient department if
they have any of the following features:
Raised temperature, especially when
associated with rigors;
Cellulitis with soft, uctuant areas
suggestive of abscess formation;
A red streak from an area of cellulitis or
a progressively fast-spreading area of
redness;
Signicant pain not relieved by
recommended analgesia;
Inability to move an extremity or joint
because of pain;
Nausea and vomiting.
Patients with diabetes, cancer or immu-
nosuppression should be made aware that
localised cellulitis may become serious.
Conclusion
Health professionals need to consider cel-
lulitis as a multidisciplinary issue that
requires more than just treating the infec-
tion. Assessment has to be all-inclusive to
manage patient care effectively and, in
many, the aim is to avoid recurrent epi-
sodes. Good background knowledge of
common presenting skin disease is essen-
tial and practitioners should have ade-
quate knowledge to diagnose, treat or
refer. Awareness of risk factors is also
important not only in the initial assess-
ment but also to educate patients about
ongoing management and prevention. NT
The continuing professional
development e-learning site below has
more information on topical
corticosteroids and is an excellent learning
resource (www.topicalsteroids.co.uk).
References
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management of leg ulcers. Wound Essentials; 1: 20-37.
Barron GS et al (2007) Dermatologic complications
of venous disease: medical management and
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Beldon P (2009) Managing wet legs in patients
with chronic oedema. Wounds UK; 5: 2, 20-23.
Bjrnsdttir S et al (2005) Risk factors for acute
cellulitis of the lower limb: a prospective case-control
study. Clinical Infectious Diseases; 41: 10, 1416-1422.
Clinical Resource Efciency Support Team (2005)
CREST Guidelines on the Management of Cellulitis in
Adults. Belfast: CREST. tinyurl.com/CREST-cellulitis
Corwin P et al (2005) Randomised controlled trial
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home compared with hospital. British Medical
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McNamara DR et al (2007) Incidence of
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Table 1. Comparing clinical features of venous stasis eczema and cellulitis of the leg
Venous stasis eczema Cellulitis
Symptoms Apyrexial May have pyrexia
Itching Painful
History of varicose veins or
deep vein thrombosis
No relevant history
Signs Erythematous, inamed Erythematous, inamed
No tenderness Tenderness
Vesicles One or a few bullae
Crusting No crusting
Other lesions on body No other lesions
Portal of entry Not applicable Usually unknown but may be
ulceration or associated skin
disease eczema/tinea pedis
Investigations White blood count normal White blood count high
Blood culture negative Blood culture usually negative
Skin swabs Staphylococcus
aureus common
Usually negative except for
necrotic tissue
Source: Quartey-Papao (1999)
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