Journal reading

RECURRENT ERYSIPELAS – RISK FACTORS AND

CLINICAL PRESENTATION
Putu Gde Hari Wangsa

Supervised by :
DR.dr. Luh Made Mas Rusyati. SpKK(K),FINSDV,FAADV
 INTRODUCTION

 Erysipelas is defined as an acute onset of local signs of

inflammation such as progressing erythema, associated
with pain and swelling, clearly demarcated from the
surrounding tissue.
Erysipelas?

 Risk factor : disruption of the cutaneous barrier, venous

insufficiency, lymphedema and overweight
 whereas risk factors for recurrence are less well defined

Objective to clarify risk factors for erysipelas recurrence. And assessing
whether the clinical presentation in episodes of recurrent erysipelas differ
from single episodes
MATERIAL AND METHODS

Population : All patients ≥ 18 years of age, both hospitalized

and outpatients, diagnosed with erysipelas at the
Department of Infectious Diseases, Skåne University Hospital,
Lund Sweden, between January 2007 and February 2011.

Methods : Cross sectional study

Data collection : January 502 patients as subjects

2007 and February 2011 from
secondary data (medical Individuals with SE, n = 360
records), all data was (71%), were compared with
anonymized before analysis those with RE, n = 142 (29%)
 RESULT

• Individuals with SE, n

= 360 (71%), were
compared with
those with RE, n = 142
(29%).

• Individuals with RE
were more prone to
seek medical care
earlier (<12 hr since
onset)

• Neither other clinical

presentations
distribution differed
between the groups.
• There was statistical evidence for the risk factor of RE such as local operation,
location of erysipelas in lower limbs, malignancy, venous insufficiency and
lymphedema, where they reach statistical significance (P<0.01)
• Thus, the association between RE and underlying factors, although these did
not reach statistical significance. (P>0.01)
RESULT

• Erysipelas in the lower limbs had the greatest propensity of recurrence. The
associations between underlying conditions and recurrence were largely
depending on the site of erysipelas.

• Overall, the most prominent risk factor for recurrence was lymphedema
and other conditions causing a chronic impairment of the defense against
microbes.

• Individuals with recurrent erysipelas tended to seek medical attention

earlier, and were less likely to be hospitalized or receive intravenous
antibiotics, but there was no evidence of any difference in inflammatory
reaction when taking confounding factors into account.
DISCUSSION

In this large study of over 500 patients with erysipelas, we found lymphedema
to be the most prominent risk factors for recurrence although the distribution
of predisposing conditions varies depending on the site of erysipelas

This study has several strengths. It is one of the largest of its kind, which
permits analyses of erysipelas per site of infection as well as adjustments
for coexisting risk factors.

There are also some limitations to this study. The retrospective design allow
only available information restricted to medical records.
CONCLUSION

This study shows that a large proportion of cases with erysipelas

are RE but these episodes do not seem to be more severe than
SE.

The most prominent risk factor for recurrence is

lymphedema, regardless of the site of erysipelas, and other
conditions causing a chronic impairment of the defence
against microbes

Whereas conditions, temporarily disrupting the skin barrier (e.g.

a local wound or toe web intertrigo), although being risk
factors for erysipelas per se, did not seem to predispose to
repeated episodes.
CRITICAL APPRAISAL
A. Are the results of this cross-sectional
study valid ?
1. Did the study Address a clearly focused issue ?
YES
They aim to clarify risk factors for erysipelas recurrence.
And assessing whether the clinical presentation in
episodes of recurrent erysipelas differ from single episodes

2. Did the Authors use an appropriate method to

answer the question?
YES
- The design of the study was cross-sectional
3. Were the subjects recruited in an acceptable way ?
YES

• The study use secondary data from medical records

• It was conducted in the Department of Infectious Diseases, Skåne University

Hospital, Lund Sweden

• patients ≥ 18 years of age, both hospitalized and outpatients, diagnosed with

erysipelas, between January 2007 and February 2011.

• The patients were divided into single episode erysipelas (SE) and recurrent
erysipelas (RE). SE was defined as patients with erysipelas without a history of
previous episodes (medical records and anamnestic information). RE was defined
as patients with more than one episode of erysipelas registered during the study
period, or anamnestic information of previous episode outside the study period.
4. Were the measures accurately measured to reduce bias ?
YES
Among 601 patients who were registered, 99 were excluded due to
medical records that could not be retrieved and initial erysipelas diagnose
that changed to other diagnose during the episode

5. Were the data collected in a way that addressed the research issue ?
YES
The study used medical records to collect data, they were reviewed and
data extracted according to a pre-specified protocol, all data was
anonymized before analysis

6. Did the study have enough participants to minimize the play of

chance ?
YES
The study includes all of 502 patients both hospitalized and outpatients,
diagnosed with erysipelas between January 2007 and February 2011.
B. Are the results of this descriptive /
cross sectional study IMPORTANT?
 7. How are the result presented and what is the main result ?
The result was presented in tables as distribution of patient clinical presentation and risk factor of
recurent erysipelas
8. Was the data analysis sufficiently rigorous?
YES
Fisher’s exact tests, Chi-squared tests and analysis of variance were
used to assess the distribution of background factors in individuals,
Logistic regression was used to assess predictors of recurrence. And
the presented data support the finding
9. Is there a clear statement of findings?
YES
The findings were described clearly and concisely
C. Can you apply this cross-sectional
study in caring for your patient ?
10. The result be apply to the local population ?
YES
We can apply the results because the characteristics of our patient
are not so different with this population

11. How valuable is the research ?

This study is valuable because it tell us the clinical finding
and the risk factor of the patients for having recurrent
period erysipelas, thus we could be more aware.

APPLICABLE
, Lower leg
1. Inform the patient about risk of having recurrent episode of erysipelas,
so the patient could be aware
2. Educated patient about predisposing factor such as: DM, Obesity,
and that must be controlled
3. Seek medical treatment or health care professional as soon as
possible
4. Maintain self hygiene of the patient
Most commonly occur in lower limb
Recurrent episode of erysipelas can mostly occur in the same site of
the previous episode
Ec: The infection can damage the skin structure and function so it
could be prone to infected, but it can also occur in the different
site depend on the port the entry
STRENGTH WEAKNESS
Decrease the bias because due to The information are limited because
large number of sample size the data only gathered from
medical record
A lot of variable are evaluate
Because this research use medical
record as the source of data, it will
reduce the bias due to patient
recall
Necrotizing fasciitis
• Characterized by rapid progression of infection with extensive
necrosis of soft tissue and overlying skin
• My cause rapid damage of skin, sepsis and life threatening

Elephantiasis nostras verrucosa (ENV)

• a rare form of chronic lymphedema that causes progressive
cutaneous hypertrophy  deformity
• Characterized by nonpitting edema and superimposed
hyperkeratotic papulonodules with a verrucose or cobblestone-like
appearance.
CROSS SECTIONAL STUDY