Facial cellulitis

Background

• Superficial soft tissue infection of the face
• Risk factors include immunosuppression, diabetes, vascular injury (due to radiation or trauma), foreign bodies
• Most commonly caused by S. pyogenes and S. aureus, including MRSA

Clinical Features

• Erythema, edema, warmth, pain
• Can be associated with chronic illness, trauma, insect bites, allergen exposure, dental caries, radiation exposure
• Consider severe illness or sepsis with systemic symptoms (fever, tachycardia, hypotension, AMS)

Differential Diagnosis

Infectious

• Cellulitis
• Impetigo
• Erysipelas
• Viral exanthem
• Parotitis
• Necrotizing fasciitis
• Anthrax
• Herpes zoster
• Malignant otitis externa

Trauma

• Soft tissue contusion
• Burn

Inflammatory

• Insect bite
• Apical abscess
• Contact dermatitis

Immunologic

• Systemic lupus erythematosus
• Vancomycin flushing reaction
• Angioneurotic edema

Evaluation

• Diagnosis is clinical
• Consider labs, blood cx if patient is immunocompromised, risk factors, renal dysfunction
• Bedside US to identify abscess
• CT can identify deep, extensive infection that involve soft tissues of neck or pharynx

Management

• Analgesics
• Remove foreign bodies from affected area if possible
• Abscesses should be drained

Antibiotics

Tailor antibiotics by regional antibiogram

Outpatient

• 5 day treatment duration
  • Cephalexin 500mg PO q6hrs OR
    • Add DS 1 tab PO BID if MRSA suspected
  • Clindamycin 450mg PO TID covers Strep and Staph

Pediatric Outpatient

• Cephalexin 25-50mg/kg/day PO divided q6-8h (max 500mg/dose) OR
  • Add 8-12mg/kg/day (TMP) PO divided BID if MRSA suspected
• Clindamycin 30-40mg/kg/day PO divided TID (max 1.8g/day)

Inpatient

• Vancomycin 20mg/kg IV q12hrs OR
• Clindamycin 600mg IV q8hrs OR
• Linezolid 600mg IV q12hrs OR
• Daptomycin 4mg/kg IV once daily

Pediatric Inpatient

• Vancomycin 15mg/kg IV q6hrs OR
• Clindamycin 10-13mg/kg IV q8hrs (max 900mg/dose) OR
• Linezolid <12yr: 10mg/kg IV q8hrs; >12yr: 600mg IV q12hrs

Saltwater related cellulitis

• Doxycycline 100mg PO/IV q12hrs daily + Cefepime 1g IV q12hrs x 10 days
• Ciprofloxacin 400mg IV q12hrs x 10 days

Freshwater related cellulitis

• Ciprofloxacin 500mg PO q12hrs x 10 days
• TMP/SMX 2 DS tablets PO q12hrs x 10 days
• Ceftriaxone 1g (50mg/kg) IV q24hrs

Disposition

• Most patients can be treated with oral antibiotics as outpatient
• Consider admission for:
  • systemic signs of sepsis
  • antibiotic intolerance
  • immunosuppression
  • extensive areas of erythema or induration
  • foreign bodies that cannot be removed in ED
  • failure of outpatient therapy

See Also

• Cellulitis