Providing Evidence Based Care for Patients with Lower-Extremity Cellulitis

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Cellulitis is an acute, painful and potentially serious spreading bacterial skin infection that affects mainly the subcutaneous and dermal layers. Usually an acute onset, with redness, warmth, swelling and tenderness. Borders for the affected skin are irregular. In cellulitis, bacteria enter through an opening in the skin caused by a bite, an ulcer, a body piercing, or other discontinuity. Risk factors for cellulitis is common in patients with circulatory problems of the legs, particularly those with venous disease.

Cellulitis is diagnosed based on classic symptoms, which include a unilateral hot, erythematous, nonblanching redness that persist with limb elevation. Skin may be dry and flaking. Subcutaneous tissue is tender; in severe cellulitis, crepitation may occur.

Differentiating cellulitis from other conditions may prove challenging. Disorders that can mimic cellulitis include eczema, tinea pedis, and other chronic conditions such as erysipelas. Lipodermatosclerosis also may be mistaken for cellulitis. 

Unlike cellulitis, venous eczema can cause a range of manifestations, such as bilateral symptom, itching, hemosiderin deposits and edema. Suspect venous eczema, not cellulitis, in a patient with reddened leg skin, chronic venous disease or an ulcer and a history of appropriate antibiotics with no improvement.  Dependent rubor from peripheral vascular disease also may resemble cellulitis.

If you suspect cellulitis, assess for induration – a hardened mass or formation with defined edges, with slight swelling and firmness at the edges or border between normal skin and skin affected by cellulitis. Elevating the affected leg above heart level is a key intervention for cellulitis. Raise the ankle higher than the knee, the knee higher than the hip, and the entire leg higher than heart level. Continue elevation for the first 24 to 48 hours while I.V. antibiotics are infusing.

Measure the patient’s temperature on an ongoing basis. Expect to obtain blood cultures as a standard of care. Signs and symptoms of systemic infection include chills, sweating, fatigue, general malaise, muscle ache, and sensation of heat. These require prompt attention.

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