Facial cellulitis

Background

• Superficial soft tissue infection of the face
• Most commonly caused by S. pyogenes and S. aureus, including MRSA

Risk Factors

• immunosuppression
• diabetes
• vascular injury (due to radiation or trauma)
• foreign bodies

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

Facial cellulitis

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

Skin and Soft Tissue Infection

• Cellulitis
  • Hand cellulitis
  • Facial cellulitis
  • Orbital cellulitis
• Erysipelas
• Lymphangitis
• Folliculitis
• Hidradenitis suppurativa
• Skin abscess
  • Anorectal abscess
  • Bartholin gland abscess
  • Pilonidal abscess
  • Scrotal abscess
• Necrotizing soft tissue infections
  • Necrotizing fasciitis
  • Necrotizing myositis
  • Necrotizing cellulitis
  • Fournier's gangrene
• Mycobacterium marinum

Look-A-Likes

• Sporotrichosis
• Osteomyelitis
• Deep venous thrombosis
• Pyomyositis
• Purple glove syndrome
• Tuberculosis (tuberculous inflammation of the skin)

Evaluation

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

Management

1. Analgesics
2. Remove foreign bodies from affected area if possible
3. Abscesses should be drained
4. Antibiotics (see below)

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