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Risk factor for cellulitis. Cellulitis: Causes, Risk Factors, and Prevention Strategies

by alexxlab

What are the common causes of cellulitis. How can you identify risk factors for cellulitis. What preventive measures can be taken to reduce the risk of developing cellulitis. How does a weakened immune system contribute to cellulitis risk. Why do certain skin conditions increase the likelihood of cellulitis.

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Understanding Cellulitis: A Potentially Serious Bacterial Skin Infection

Cellulitis is a bacterial infection that develops in the deeper layers of the skin, beneath the epidermis. This condition can escalate rapidly, making prompt medical attention crucial for anyone exhibiting symptoms. The primary culprits behind most cellulitis cases are Staphylococcus (staph) and Streptococcus (strep) bacteria, which can harmlessly reside on intact skin but become problematic when the skin barrier is compromised.

Key Symptoms of Cellulitis

  • Swelling in the affected area
  • Redness and warmth of the skin
  • Pain and tenderness
  • Possible blisters
  • Fever and chills in some cases
  • Nausea

Is cellulitis a life-threatening condition? While cellulitis is treatable with antibiotics, if left unchecked, it can potentially spread to the bloodstream, leading to a severe, life-threatening situation. This underscores the importance of early detection and treatment.

Common Causes and Entry Points for Cellulitis

Cellulitis often originates from minor skin injuries that provide an entry point for bacteria. These can include:

  • Scratches or cuts
  • Abrasions
  • Insect bites
  • Other types of skin trauma

How can you prevent cellulitis from developing after a skin injury? Proper wound care is essential. Clean the affected area with soap and water, apply a thin layer of antibiotic ointment, and cover with a bandage. Regular inspection of the wound for signs of infection, such as increased redness, swelling, or drainage, is crucial.

Dr. Amesh A. Adalja, a board-certified infectious disease physician, emphasizes the importance of wound care: “People with wounds should avoid exposure to fresh water, dirt, and the like, and wounds should be inspected daily to check for signs of infection.”

Identifying Risk Factors for Cellulitis

While anyone can develop cellulitis, certain factors increase the risk. Understanding these risk factors can help individuals take appropriate preventive measures.

Weakened Immune System

A compromised immune system significantly raises the risk of cellulitis. Factors that can weaken the immune system include:

  • Age (very young and elderly individuals)
  • Chronic conditions like diabetes, cancer, HIV, and AIDS
  • Kidney or liver disease
  • Recent surgery
  • Autoimmune diseases such as lupus or rheumatoid arthritis
  • Use of immunosuppressant drugs or corticosteroids

How does a weakened immune system increase cellulitis risk? Dr. Adalja explains, “A weakened immune system makes the task of invading bacteria easier, as it has less of a burden to contend with when it invades tissues.”

History of Skin Problems

Individuals with a history of certain skin conditions are at higher risk of developing cellulitis. These conditions include:

  • Impetigo
  • Athlete’s foot
  • Contact dermatitis
  • Atopic dermatitis
  • Shingles
  • Chickenpox

Why do these skin conditions increase cellulitis risk? These conditions can cause breaks in the skin, providing an entry point for bacteria. For example, impetigo, caused by the same bacteria that cause cellulitis, can lead to small bumps or blisters that rupture, potentially allowing bacteria to penetrate deeper layers of the skin.

Obesity and Lymphedema: Additional Risk Factors for Cellulitis

Obesity and lymphedema are two conditions that can significantly increase an individual’s risk of developing cellulitis. Understanding how these factors contribute to cellulitis risk can help in developing targeted prevention strategies.

Obesity and Cellulitis Risk

How does obesity contribute to cellulitis risk? Excess body weight can lead to several factors that increase susceptibility to cellulitis:

  • Compromised skin integrity due to friction and moisture in skin folds
  • Reduced circulation, particularly in the lower extremities
  • Potential weakening of the immune system
  • Increased difficulty in maintaining proper hygiene in all areas of the body

These factors create an environment more conducive to bacterial growth and infection, thereby increasing the risk of cellulitis in obese individuals.

Lymphedema and Its Impact on Cellulitis Risk

Lymphedema, a condition characterized by swelling due to a buildup of lymph fluid in the body’s tissues, significantly increases the risk of cellulitis. But why is this the case?

  • Compromised lymphatic system: The impaired drainage of lymph fluid can create an environment where bacteria thrive
  • Reduced immune response: The affected area may have a diminished ability to fight off bacterial invaders
  • Skin changes: Chronic lymphedema can lead to skin changes that make it more susceptible to breaks and subsequent infection

Individuals with lymphedema must be particularly vigilant about skin care and infection prevention to reduce their risk of cellulitis.

The Role of Intravenous Drug Use in Cellulitis Risk

Intravenous (IV) drug use significantly increases the risk of cellulitis. This elevated risk is due to several factors associated with the practice:

  • Non-sterile injection techniques
  • Contaminated drugs or equipment
  • Repeated skin punctures
  • Compromised overall health and immune function

How does IV drug use lead to cellulitis? The repeated introduction of needles through the skin creates numerous entry points for bacteria. When combined with potentially contaminated substances and equipment, this practice significantly increases the likelihood of bacterial infection, including cellulitis.

Moreover, individuals engaged in IV drug use may delay seeking medical attention, allowing infections to progress to more severe stages. This delay can transform a treatable condition into a life-threatening situation.

Prevention Strategies for Cellulitis

While it’s not always possible to prevent cellulitis, several strategies can significantly reduce the risk of developing this bacterial skin infection:

Proper Wound Care

  1. Clean all wounds promptly with soap and water
  2. Apply an antibiotic ointment to minor cuts and scrapes
  3. Cover wounds with a sterile bandage
  4. Change bandages daily or when they become dirty or wet
  5. Monitor wounds for signs of infection

Skin Hygiene and Moisturizing

How can proper skin care help prevent cellulitis?

  • Keep skin clean and well-moisturized to prevent cracks and dryness
  • Use mild soaps and moisturizers suitable for your skin type
  • Pay special attention to areas prone to dryness or cracking, such as feet and hands

Managing Underlying Conditions

Effective management of conditions that increase cellulitis risk is crucial. This includes:

  • Proper diabetes management to maintain healthy blood sugar levels
  • Treatment of chronic skin conditions like eczema or psoriasis
  • Addressing circulatory issues
  • Managing lymphedema through prescribed therapies and compression garments

Lifestyle Modifications

What lifestyle changes can help reduce cellulitis risk?

  • Maintain a healthy weight through proper diet and exercise
  • Quit smoking, as it can impair circulation and wound healing
  • Practice good hygiene, especially in high-risk environments
  • Avoid walking barefoot in public areas to prevent cuts and infections

When to Seek Medical Attention for Potential Cellulitis

Recognizing the signs of cellulitis and seeking prompt medical attention is crucial for effective treatment. But when should you consult a healthcare professional?

Signs That Warrant Immediate Medical Attention

  • Rapidly spreading redness or swelling
  • Severe pain or tenderness in the affected area
  • Fever or chills
  • Skin that feels hot to the touch
  • Formation of blisters or oozing from the affected area
  • Red streaks extending from the initial site of infection

Is cellulitis always a medical emergency? While not always an emergency, cellulitis can progress rapidly and should be evaluated by a healthcare professional as soon as possible. This is particularly important for individuals with weakened immune systems or other risk factors.

Special Considerations for High-Risk Individuals

Certain groups should be especially vigilant and seek medical attention promptly, even for minor skin injuries or signs of infection:

  • People with diabetes
  • Individuals with compromised immune systems
  • Those with a history of cellulitis
  • People with chronic skin conditions
  • Individuals with lymphedema

For these high-risk groups, early intervention can prevent the development of cellulitis or catch it in its early stages when it’s most treatable.

Treatment Approaches for Cellulitis

While prevention is crucial, understanding the treatment options for cellulitis is equally important. How is cellulitis typically treated?

Antibiotic Therapy

The primary treatment for cellulitis is antibiotic therapy. The specific antibiotic prescribed depends on several factors:

  • Severity of the infection
  • Location of the infection
  • Suspected causative bacteria
  • Patient’s overall health and medical history

Antibiotics may be administered orally for mild to moderate cases, while severe cases might require intravenous antibiotics in a hospital setting.

Supportive Care

In addition to antibiotics, supportive care measures are often recommended:

  • Elevation of the affected limb to reduce swelling
  • Rest to promote healing
  • Pain management with over-the-counter or prescription medications
  • Application of cool, wet compresses to the affected area

Monitoring and Follow-up

How long does it take for cellulitis to respond to treatment? While improvement is often seen within a few days of starting antibiotics, complete resolution may take 7-10 days or longer. Regular follow-up with a healthcare provider is essential to ensure the infection is resolving and to adjust treatment if necessary.

In cases where cellulitis doesn’t respond to initial treatment or continues to spread, hospitalization may be required for more intensive therapy and monitoring.

Understanding the causes, risk factors, prevention strategies, and treatment approaches for cellulitis empowers individuals to take proactive steps in maintaining skin health and seeking timely medical attention when needed. By staying informed and vigilant, the risk of developing this potentially serious bacterial skin infection can be significantly reduced.

Cellulitis Causes, Risk Factors, and Prevention

By Valencia HigueraMedically Reviewed by Mohiba Tareen, MD

Reviewed:

Medically Reviewed

Athlete’s foot can raise the risk of cellulitis if it causes breaks in the skin.Getty Images

Cellulitis is a potentially serious bacterial infection that develops in the deep layers of the skin, below the epidermis. It can get worse quickly, so if you develop signs or symptoms of cellulitis, you should see a doctor right away.

Signs and symptoms of cellulitis include swelling, redness, pain, and tenderness in the affected area. Some people also develop blisters, chills, fevers, and nausea. (1)

Cellulitis is treatable with antibiotics. But if it goes untreated, the infection can get into the bloodstream and become life-threatening.

Even though cellulitis isn’t always preventable, understanding its causes and risk factors may lower your risk of this infection.

Common Causes of Cellulitis

The two types of bacteria that cause most cases of cellulitis are Staphylococcus (staph) and Streptococcus (strep). Both can live harmlessly on intact skin, but when the skin is broken, the result can be a bacterial infection of the top or deeper layers of the skin. (2)

The strep bacterium is the same one that causes strep throat, and in rare cases, cellulitis occurs as a complication of strep throat, according to an article published in the journal American Family Physician. (3)

More commonly, cellulitis starts with a minor scratch, cut, abrasion, bug bite, or another skin injury. Taking care of these injuries promptly can prevent infection and the development of cellulitis. (4)

“Wounds should be cleaned with soap and water, covered with a thin layer of an antibiotic ointment, and then covered with a bandage,” says Amesh A. Adalja, MD, a board-certified infectious disease physician in Pittsburgh and a senior scholar and assistant professor at the Johns Hopkins University Center for Health Security in Baltimore.

“People with wounds should avoid exposure to fresh water, dirt, and the like, and wounds should be inspected daily to check for signs of infection, which could include redness, drainage, and swelling,” Dr. Adalja adds.

Most skin injuries heal best when they are covered with gauze or an adhesive bandage that keeps the wound surface moist, but not wet. (5) Change the bandage daily after examining the wound for signs of infection — or more frequently if the bandage gets dirty.

While many wounds can be treated at home, see a doctor for deeper injuries, particularly those that won’t stop bleeding, or if you believe you might need stitches.

People with diabetes, in particular, should see a doctor if they don’t see signs of wound healing within a day or two.

Risk Factors for Cellulitis

Most people will have many minor skin injuries over their lifetimes and never develop a skin infection. Yet others may develop repeated skin infections after equally minor injuries. Why is this?

Certain conditions raise the risk of developing cellulitis and other skin infections. Those conditions include having a weakened immune system, having a history of cellulitis or other skin problems (such as psoriasis or eczema), being obese or overweight, lymphedema, and use of illicit injectable drugs.

Weak Immune System

Some people develop infections easily because their immune systems aren’t strong enough to protect them from bacteria and other germs.

“A weakened immune system makes the task of invading bacteria easier, as it has less of a burden to contend with when it invades tissues,” explains Adalja.

Children and the elderly typically have weaker immune systems and thus are at greater risk of cellulitis than young and middle-aged adults.

A number of medical conditions also weaken the immune system. These include diabetes, cancer, HIV, and AIDS. You may also have a weaker immune system if you have kidney or liver disease or if you’ve recently had surgery. (2)

An autoimmune disease — such as lupus or rheumatoid arthritis — can also weaken the immune system. This not only makes you vulnerable to cellulitis, but also to other infections, such colds and the flu.

Taking an immunosuppressant drug to treat an autoimmune disease or any other disease also lowers your body’s ability to fight off invaders. (2) Corticosteroid drugs can have a similar effect.

History of Skin Problems

Cellulitis can occur as a complication of impetigo, a bacterial skin infection of the top layer of skin.

Impetigo is also commonly caused by the staph or strep bacteria. People with impetigo typically develop small bumps or blisters that rupture and form crusty scabs. Treatment for impetigo involves taking antibiotics. (6)

You can also get cellulitis when another skin condition causes a break in your skin. Such conditions include athlete’s foot, contact dermatitis, atopic dermatitis, shingles, and chickenpox.

Having one bout of cellulitis increases your chances of another infection. (1) In fact, some people deal with multiple infections in a year. In some cases, a doctor may recommend a continuous, low-dose antibiotic to prevent recurrent episodes of cellulitis. (7)

Frequent skin injuries — because of occupational, recreational, or other types of activities — also raise the risk for cellulitis. (2)

Being Obese or Overweight

Excess weight puts you at risk for cellulitis, because being overweight can make it harder for the body to fight infections. (8)

Being obese or overweight also increase the risk of developing lymphedema, another cellulitis risk factor, after cancer or cancer treatment, or from other causes. (9)

Lymphedema

Fluid buildup in the arms and legs, called lymphedema, increases the risk for cellulitis. A common cause of lymphedema in the arms is the removal of lymph nodes between the breast and underarm during treatment for breast cancer.

Lymphedema in the legs can also occur as a result of cancer treatment, injury to the lymph nodes or lymph vessels in the legs, or certain infections.

Injection Drug Use

Previous research indicates that skin infections, including cellulitis, are common among injection drug users, particularly when users inject directly into skin or muscle tissue, rather than into a vein. (10) Use of unsterilized needles and inadequate skin cleansing before injection also raise the risk of infection, according to an article in the journal Archives of Clinical Microbiology. (11)

Of course, self-injecting drugs to get high has many other negative health and social effects besides skin infections. Getting treatment for a drug addiction is generally necessary to stop using drugs, stay off them, and pursue more productive life activities.

Cellulitis Prevention Tips

There are several steps you can take to prevent cellulitis from occurring in the first place or to prevent recurrent infections:

Protect Your Skin From Injury

Take precautions to avoid or prevent even minor skin injuries by doing the following:

  • Apply sunscreen and insect repellent when spending time outdoors.
  • Don’t pick at or scratch your skin.
  • Keep your fingernails trimmed to help prevent scratching.
  • Follow your doctor’s orders for treating eczema and other rashes or skin conditions.
  • Learn to use knives and other sharp tools properly.
  • Avoid burns when cooking by using hot pads to handle hot pots and pans and by wearing gloves when washing dishes.
  • For construction or DIY projects or when using hazardous chemicals, wear protective gloves, boots, and safety goggles.
  • When playing sports, wear appropriate protective gear.
  • Don’t walk around barefoot, especially outdoors, and especially if you have diabetes.
  • Don’t attempt “bathroom surgery” on calluses or corns.

Treat Wounds Promptly and Properly

If you do sustain a skin injury, clean it thoroughly with soap and water to rinse out any dirt, debris, or bacteria before an infection takes hold. Cover cuts, scrapes, burns, and broken blisters with gauze or an adhesive bandage.

Keep injuries covered until they heal, changing the bandage daily.

Monitor wounds and look for any signs of infection. If your symptoms get worse rather than better, progress quickly, or become severe, go to the emergency department, warns Tsippora Shainhouse, MD, a board-certified dermatologist at SkinSafe Dermatology and Skin Care in Beverly Hills, California, and a clinical instructor at the University of Southern California.

“Regular reassessment of the skin by a healthcare provider is critical for appropriate management,” Dr. Shainhouse notes.

Wash Your Hands Regularly

Regularly washing your hands can also stop the spread of some bacterial infections. You should wash hands for at least 20 seconds, which is the length of singing the “Happy Birthday” song twice. (12)

Dry your hands with a clean cloth, and apply moisturizer to your hands and skin on a regular basis. This can prevent skin dryness and cracking.

Make Healthy Lifestyle Changes

Since being obese or overweight can increase the risk for cellulitis, take steps toward losing some weight by limiting your intake of sugar and fast food, eating plenty of unprocessed fruits and vegetables, and increasing your daily physical activity.

You should also stop smoking if you smoke, and limit your intake of alcohol to no more than one drink per day for women and no more than two drinks per day for men. Both smoking and heavy drinking can increase the risk of cellulitis.

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Editorial Sources and Fact-Checking

  1. Cellulitis: Overview. Mayo Clinic. May 6, 2022.
  2. Cellulitis: Who Gets and Causes. American Academy of Dermatology.
  3. Shaughnessy, AF. Suppurative Complications of Sore Throat Uncommon and Unpredictable. American Family Physician. May 15, 2014.
  4. Cellulitis. Johns Hopkins Medicine.
  5. Should You Bandage a Cut or Sore or Let It Air Out? Cleveland Clinic. March 10, 2021.
  6. Impetigo: Overview. Mayo Clinic. April 27, 2022.
  7. Cellulitis: How to Prevent It From Returning. American Academy of Dermatology.
  8. Deivert S, Fleetwood M. Obesity and the Immune System. Obesity Action Coalition.
  9. Lymphedema. Mayo Clinic. September 18, 2021.
  10. Ebright JR, Pieper B. Skin and Soft Tissue Infections in Injection Drug Users. Infectious Disease Clinics of North America. September 2002.
  11. Tyagi R. Extremity Infections in Intravenous Drug Users [PDF]. Archives of Clinical Microbiology. April 21, 2016.
  12. When and How to Wash Hands. Centers for Disease Control and Prevention. March 14, 2022.

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Cellulitis – StatPearls – NCBI Bookshelf

Continuing Education Activity

Cellulitis is a common bacterial skin infection, with over 14 million cases occurring in the United States annually. This activity educates the learner on the etiology, epidemiology, evaluation, and treatment of cellulitis. It provides the latest updates on how to accurately diagnose, effectively treat, and manage patients with bacterial cellulitis. Upon completing the activity, the learner should be able to differentiate cellulitis from other mimickers correctly. The learner will know how to discern when cellulitis treatment is appropriate in the outpatient setting with oral antibiotics versus when a patient should be hospitalized and treated with intravenous antibiotics, and how the interprofessional team can best manage patients with cellulitis.

Objectives:

  • Identify the etiology of cellulitis.

  • Review the evaluation process for cellulitis.

  • Summarize the treatment and management options available for cellulitis.

  • Outline interprofessional team strategies for improving care coordination and communication to advance the management and proper treatment of cellulitis.

Access free multiple choice questions on this topic.

Introduction

Cellulitis is a common bacterial skin infection, with over 14 million cases occurring in the United States annually. It accounts for approximately 3.7 billion dollars in ambulatory care costs and 650000 hospitalizations annually.[1] Cellulitis typically presents as a poorly demarcated, warm, erythematous area with associated edema and tenderness to palpation. It is an acute bacterial infection causing inflammation of the deep dermis and surrounding subcutaneous tissue. The infection is without an abscess or purulent discharge. Beta-hemolytic streptococci typically cause cellulitis, generally group A streptococcus (i. e., Streptococcus pyogenes), followed by methicillin-sensitive Staphylococcus aureus. Patients who are immunocompromised, colonized with methicillin-resistant Staphylococcus aureus, bitten by animals, or have comorbidities such as diabetes mellitus may become infected with other bacteria.[2] If the clinician correctly identifies and promptly treats cellulitis, it typically resolves with appropriate antibiotic treatment.

Etiology

The skin serves as a protective barrier preventing normal skin flora and other microbial pathogens from reaching the subcutaneous tissue and lymphatic system. When a break in the skin occurs, it allows for normal skin flora and other bacteria to enter into the dermis and subcutaneous tissue. The introduction of these bacteria below the skin surface can lead to an acute superficial infection affecting the deep dermis and subcutaneous tissue, causing cellulitis. Cellulitis most commonly results from infection with group A beta-hemolytic streptococcus (i. e., Streptococcus pyogenes).[3]

Risk factors for cellulitis include any culprit that could cause a breakdown in the skin barrier such as skin injuries, surgical incisions, intravenous site punctures, fissures between toes, insect bites, animal bites, and other skin infections.[4] Patients with comorbidities such as diabetes mellitus, venous insufficiency, peripheral arterial disease, and lymphedema are at higher risk of developing cellulitis.[5]

Epidemiology

Cellulitis is relatively common, and most often occurs in middle-aged and older adults. When comparing men and women, there is no statistically significant difference in the incidence of cellulitis. There are approximately 50 cases per 1000 patient-years.[6]  

Pathophysiology

Cellulitis is characterized by erythema, warmth, edema, and tenderness to palpation resulting from cytokine and neutrophil response from bacteria breaching the epidermis. The cytokines and neutrophils are recruited to the affected area after bacteria have penetrated the skin leading to an epidermal response. This response includes the production of antimicrobial peptides and keratinocyte proliferation and is postulated to produce the characteristic exam findings in cellulitis.[7] Group A Streptococci, the most common bacteria to cause cellulitis, can also produce virulence factors such as pyrogenic exotoxins (A, B, C, and F) and streptococcal superantigen that can lead to a more pronounced and invasive disease.[8]

History and Physical

Patients with cellulitis will reveal an affected skin area typically with a poorly demarcated area of erythema. The erythematous area is often warm to the touch with associated swelling and tenderness to palpation. The patient may present with constitutional symptoms of generalized malaise, fatigue, and fevers.

When evaluating patients presenting with cellulitis, clinicians should ask for a complete history of the presenting illness, focusing on the context in which the patient noticed the skin changes or how the cellulitis began to occur. It is essential to ask patients if they: recently traveled, experienced any trauma or injuries, have a history of intravenous drug use, and/or have had insect or animal bites to the affected area. A complete and thorough past medical history should additionally be conducted to evaluate for possible chronic medical conditions that predispose patients to cellulitis, such as diabetes mellitus, venous stasis, peripheral vascular disease, chronic tinea pedis, and lymphedema.

The affected area should be thoroughly inspected to look for any area of skin breakdown. The area should be demarcated with a marker to monitor for continuous spread. The area should be palpated to feel for fluctuance that could indicate the formation of a possible abscess. When gently palpating the affected area, be sure to note any presence of warmth, tenderness, or purulent drainage. 

Cellulitis can present on any area of the body, but most often affects the lower extremities. It is rarely bilateral.  In lower extremity cellulitis, careful examination between interspaces of the toes should take place. [9] Additionally, if any extremities are affected, check for proper sensation and verify pulses are intact to monitor closely for compartment syndrome. One should also make a note of developing vesicles, bullae, or the presence of peau d’orange and lymphadenopathy.

Evaluation

Cellulitis is diagnosed clinically based on the presence of spreading erythematous inflammation of the deep dermis and subcutaneous tissue. It characteristically presents with worsening erythema, edema, warmth, and tenderness. Two of the four criteria (warmth, erythema, edema, or tenderness) are required to make the diagnosis. Its most common presentation is on the lower extremities but can affect any area of the body. It is most often unilateral and rarely (if ever) presents bilaterally. The patient’s skin should be thoroughly evaluated to find the potential source for the cellulitis by looking for microabrasions of the skin secondary to injuries, insect bites, pressure ulcers, or injection sites. If cellulitis is affecting the patient’s lower extremities, careful evaluation should be made to look between the patient’s toes for fissuring or tinea pedis.  Additionally, it can affect the lymphatic system and cause underlying lymphadenopathy. The associated edema with cellulitis can lead to the formation of vesicles, bullae, and edema surrounding hair follicles leading to peau d’orange. 

The Infectious Disease Society of America practice guidelines recommends against imaging the infected area except in patients with febrile neutropenia. Consider blood cultures only in patients that are immunocompromised, experienced an immersion injury or animal bite.[9] Blood cultures are also necessary when a patient has signs of systemic infection.[8]

Treatment / Management

Patients presenting with mild cellulitis and displaying no systemic signs of infection should be covered with antibiotics that target the treatment of streptococcal species. Though believed to be a less common cause, consider coverage of MSSA. The duration of oral antibiotic therapy should be for a minimum duration of 5 days. In nonpurulent cellulitis, patients should receive cephalexin 500 mg every 6 hours. If they have a severe allergic reaction to beta-lactamase inhibitors, treat with clindamycin 300 mg to 450 mg every 6 hours.

In patients with purulent cellulitis, methicillin-resistant staph aureus colonization, cellulitis associated with an abscess or extensive puncture wounds, or a history of intravenous drug use, patients should receive antibiotics that cover against methicillin-resistant staph aureus as well. Cellulitis with MRSA risk factors should be treated with trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily for 5 days in addition to cephalexin 500 mg every 6 hours. If a patient has an allergy to trimethoprim-sulfamethoxazole, treat with clindamycin 300 mg to 450 mg every 6 hours. A longer duration of antibiotic treatment may be a consideration in patients who show minimal improvement with antibiotic therapy within 48 hours. 

Hospitalization with the induction of systemic antibiotics may be necessary for patients who: present with systemic signs of infection*, have failed outpatient treatment, are immunocompromised, exhibit rapidly progressing erythema, are unable to tolerate oral medications, or have cellulitis overlying or near an indwelling medical device.

Intravenous antibiotics should be initiated to cover against group A strep. Absent patient risk factors for MRSA, treat with intravenous cefazolin, and when able de-escalate to cephalexin for a total of 5 days of treatment. If risk factors for MRSA are present, initiate therapy with Vancomycin with subsequent de-escalation to trimethoprim/sulfamethoxazole.

In immunocompromised patients requiring hospitalization for parenteral antibiotics, broad-spectrum antimicrobial coverage may be necessary with vancomycin plus piperacillin-tazobactam or a carbapenem. 

The clinician should obtain blood cultures if a patient is exhibiting signs of systemic toxicity, has persistent cellulitis despite adequate treatment, has unique exposures such as animal bites or water-associated injuries.[10]

Atypical organisms can cause cellulitis in particular situations. If exposed to a dog or cat bite, patients are at risk for developing cellulitis secondary to Pasteurella multocida. If secondary to an injury involving exposure to water, such as a cut from an oyster shell, cellulitis can be caused by Vibrio vulnificus. Diabetic patients and patients with diabetic foot ulcers are at risk for Pseudomonas aeruginosa. Immunocompromised patients are at risk for Pseudomonas aeruginosa and Cryptococcus. 

If patients have significant edema with a known cause for the edema, the underlying condition should receive proper treatment to decrease the amount of edema and prevent future episodes of cellulitis. Patients should be instructed to keep the affected area elevated.[9]

* Two or more of these systemic inflammatory response criteria: fever (over 38 degrees C), tachycardia (heart rate exceeding 90 beats/min), tachypnea (respiratory rate over 20 breaths/min), leukocytosis (white blood cells in excess of 12000/mm) leukopenia (white blood cells under 4000/mm) or bandemia greater than or equal to 10%.[9]

Differential Diagnosis

Cellulitis is a frequently encountered infection of the deep dermis and subcutaneous tissue, mainly affecting the lower extremities, but it can have many mimickers.

Erysipelas is sometimes considered a form of cellulitis. However, it is a more superficial infection affecting the upper dermis and superficial lymphatic system. Bright red erythema, elevation of the affected skin, and well-demarcated borders can help to diagnose erysipelas and distinguish it from cellulitis, which tends to be more mildly erythematous (pink) and flat with less distinct boundaries.  Erysipelas may also have streaking when superficial lymphatics are involved. It most commonly results from the exotoxins released from group A strep (Streptococcus pyogenes).  First-line treatment for erysipelas is amoxicillin or cephalexin.

Chronic venous stasis dermatitis is a long-standing, bilateral, inflammatory dermatosis secondary to chronic venous insufficiency and typically involves the medial malleoli. It appears on the lower extremities and manifests as erythema with scaling, peripheral edema, and hyperpigmentation. Treatment focuses on treating the underlying chronic venous insufficiency and its sequelae, such as lower extremity edema. [1]

Necrotizing fasciitis is a rare infection of the fascia that leads to necrosis of the subcutaneous tissue. Its characteristic presentation includes fevers, erythema, edema, pain out of proportion to the exam, and crepitus. It qualifies as a surgical emergency and requires surgical debridement immediately. Imaging may be obtained to help confirm the diagnosis of necrotizing fasciitis but should not delay surgical intervention. CT imaging revealing subcutaneous gas in the soft tissue is highly specific for necrotizing fasciitis.

Septic arthritis, or an infected joint, can involve any joint but typically involves the knee joint. Patients present with joint swelling, warmth, pain, and decreased mobility of the joint. Septic arthritis treatment is by joint aspiration and antibiotics directed at the most common pathogens.

Deep vein thrombosis (DVT) is typically unilateral and presents with tenderness, erythema, warmth, and edema.  It often affects the lower extremities. Patients commonly have the presence of risk factors for DVT, such as a history of immobility, active cancer, or a family history of venous thromboembolism. Deep vein thrombosis rarely manifests with fevers or leukocytosis, but they can be present. Ultrasound imaging is used to confirm the diagnosis.[4]

Prognosis

If the clinician promptly identifies cellulitis and initiates treatment with the correct antibiotic, patients can expect to notice an improvement in signs and symptoms within 48 hours. Annual recurrence of cellulitis occurs in about 8 to 20% of patients, with overall reoccurrence rates reaching as high as 49%.[7][1] Recurrence is preventable with prompt treatment of cuts or abrasions, proper hand hygiene, as well as effectively treating any underlying comorbidities. There is approximately an 18% failure rate with initial antibiotic treatment. Overall, cellulitis has a good prognosis.[11]

Complications

Without prompt diagnosis and treatment, cellulitis could lead to several complications. If the bacterial infection reaches the bloodstream, it could lead to bacteremia. Bacteremia is diagnosable by obtaining blood cultures in patients who exhibit systemic symptoms. The clinician should obtain identification and susceptibilities from the blood cultures and tailor antibiotics accordingly.[12] Failure to identify and treat bacteremia from cellulitis can lead to endocarditis, an infection of the inner lining (endocardium) of the heart. 

Patients who have cellulitis along with two or more SIRS criteria (fever over 100.4 degrees F, tachypnea, tachycardia, or abnormal white cell count) get diagnosed with sepsis. If cellulitis moves from the deep dermis and subcutaneous tissue to the bone, it can lead to osteomyelitis.

Cellulitis that leads to bacteremia, endocarditis, or osteomyelitis will require a longer duration of antibiotics and possibly surgery.[1]

Deterrence and Patient Education

Patients should be informed to take prescribed antibiotics as indicated. Keep the area clean and dry. When possible, they should elevate the area above the level of their heart to reduced edema.

Cellulitis should start resolving within 24 to 48 hours after initiating antibiotics. Their healthcare provider may mark the area of erythema, and patients should return if they: notice the erythema beginning to spread or not responding to antibiotics, develop persistent fevers, begin developing significant bullae, or feel the pain worsens.[9]

Patients additionally should maintain good hand hygiene and adequately clean any future abrasions in their skin.[13]

Enhancing Healthcare Team Outcomes

Treatment and prevention of cellulitis requires an interprofessional approach with the patient, healthcare provider, pharmacist, and wound care nurses. The pharmacist ideally will have a board specialty in infectious disease to assist and work with the clinician on the best antibiotic selection. The majority of patients can have management as outpatients. Patients needing inpatient treatment with parenteral antibiotics, require collaboration with multiple members of the healthcare team: physician or advanced practice provider to correctly diagnosis the severity and type of cellulitis (purulent vs. nonpurulent), nurses to help demarcate the area of erythema and monitor for worsening or improving symptoms, and pharmacist to assist with parenteral dosing and monitoring of potentially renally toxic antibiotics such as vancomycin. The wound care nurse should educate the patient on maintaining good skincare, extremity elevation, and remain ambulatory – to prevent deep vein thrombosis. The pharmacist and nurse should both counsel the patient regarding medication compliance to ensure treatment success.

A collaborative interprofessional team approach is needed for patient education to ensure successful treatment as well as patient education to prevent recurrent infections.[14][15] Level V

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Figure

Cellulitis. Contributed by DermNetNZ

Figure

Venous Insufficiency
Note the rubor (not cellulitis), atrophie blanche, and lipodermatosclerosis. Contributed by Mark A. Dreyer, DPM, FACFAS

Figure

Cellulitis of the extremity. Image courtesy O.Chaigasame

Figure

Erysipelas. Image courtesy O.Chaigasame

References

1.

Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016 Jul 19;316(3):325-37. [PubMed: 27434444]

2.

Cranendonk DR, Lavrijsen APM, Prins JM, Wiersinga WJ. Cellulitis: current insights into pathophysiology and clinical management. Neth J Med. 2017 Nov;75(9):366-378. [PubMed: 29219814]

3.

Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, Talan DA, Chambers HF., Infectious Diseases Society of America. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011 Feb 01;52(3):e18-55. [PubMed: 21208910]

4.

Quirke M, Ayoub F, McCabe A, Boland F, Smith B, O’Sullivan R, Wakai A. Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol. 2017 Aug;177(2):382-394. [PubMed: 27864837]

5.

Kaye KS, Petty LA, Shorr AF, Zilberberg MD. Current Epidemiology, Etiology, and Burden of Acute Skin Infections in the United States. Clin Infect Dis. 2019 Apr 08;68(Suppl 3):S193-S199. [PMC free article: PMC6452002] [PubMed: 30957165]

6.

McNamara DR, Tleyjeh IM, Berbari EF, Lahr BD, Martinez JW, Mirzoyev SA, Baddour LM. Incidence of lower-extremity cellulitis: a population-based study in Olmsted county, Minnesota. Mayo Clin Proc. 2007 Jul;82(7):817-21. [PubMed: 17605961]

7.

Richmond JM, Harris JE. Immunology and skin in health and disease. Cold Spring Harb Perspect Med. 2014 Dec 01;4(12):a015339. [PMC free article: PMC4292093] [PubMed: 25452424]

8.

Cunningham MW. Pathogenesis of group A streptococcal infections. Clin Microbiol Rev. 2000 Jul;13(3):470-511. [PMC free article: PMC88944] [PubMed: 10885988]

9.

Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014 Jul 15;59(2):147-59. [PubMed: 24947530]

10.

Torres J, Avalos N, Echols L, Mongelluzzo J, Rodriguez RM. Low yield of blood and wound cultures in patients with skin and soft-tissue infections. Am J Emerg Med. 2017 Aug;35(8):1159-1161. [PubMed: 28592371]

11.

Obaitan I, Dwyer R, Lipworth AD, Kupper TS, Camargo CA, Hooper DC, Murphy GF, Pallin DJ. Failure of antibiotics in cellulitis trials: a systematic review and meta-analysis. Am J Emerg Med. 2016 Aug;34(8):1645-52. [PubMed: 27344098]

12.

Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012 Feb;64(2):148-55. [PubMed: 22101078]

13.

Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004 Feb 26;350(9):904-12. [PubMed: 14985488]

14.

Singh M, Negi A, Zadeng Z, Verma R, Gupta P. Long-Term Ophthalmic Outcomes in Pediatric Orbital Cellulitis: A Prospective, Multidisciplinary Study From a Tertiary-Care Referral Institute. J Pediatr Ophthalmol Strabismus. 2019 Sep 01;56(5):333-339. [PubMed: 31545868]

15.

Gibbons JA, Smith HL, Kumar SC, Duggins KJ, Bushman AM, Danielson JM, Yost WJ, Wadle JJ. Antimicrobial stewardship in the treatment of skin and soft tissue infections. Am J Infect Control. 2017 Nov 01;45(11):1203-1207. [PubMed: 28732743]

Disclosure: Brandon Brown declares no relevant financial relationships with ineligible companies.

Disclosure: Kristen Hood Watson declares no relevant financial relationships with ineligible companies.

Stages of cellulite and its causes: how to get rid of cellulite

Cellulite is an accumulation of fat and toxins under the skin, after which the connective tissue weakens and skin deformities form. It occurs as a result of a violation of the microcirculation of the subcutaneous tissue. Most medical professionals consider cellulite to be normal for many women and some men. According to research, 85 percent of women aged 21 and older have cellulite. It appears regardless of shape or body type, so it can be found on the hips, buttocks, shoulders or abdomen, even if the weight is within the normal range. How to get rid of cellulite is an exciting question for many women. In men, it appears very rarely when there is a tendency to be overweight, and the hormonal balance is disturbed.

Body cosmetics with a profile effect, exercises, balanced nutrition and massage – that’s what will help get rid of cellulite!

Causes of cellulite

There are two main causes that cause the orange peel effect in most women.

The first cause of cellulite is the contraction of connective tissue between skin and fat. The fascial junctions of the body, called septa, are made up of elastin and collagen, and these connective tissues work like columns to support the “ceiling” that is the skin. Cellulite is more common in women than men because the collagen in women’s skin is arranged in parallel rows, like columns. This arrangement separates the fat into parts, which makes cellulite visible. Collagen in men is located in an X-shaped pattern. This creates only very small compartments and prevents dimples from appearing on the skin.

The second reason for the “orange peel” effect in cellulite is the pressure of fat cells on the skin. Over time, the body naturally produces less and less collagen and elastin, and as women age, less estrogen is produced and the blood supply to the tissues decreases, which reduces the amount of collagen in the connective tissue fibers. When the connective tissue fibers weaken, the swelling increases, increasing the appearance of cellulite on the surface of the skin. This makes the orange peel look even more noticeable as part of the skin is now pushed out while other parts are pulled in.

Other risk factors for cellulite appearance can also be distinguished:

  • age;
  • hormonal balance;
  • genetic predisposition;
  • overweight;
  • lifestyle;
  • diet high in sugar, fat and salt;
  • poor lymphatic drainage.

Cellulite stages

Cellulite development is a natural process. There are several stages or phases with a range of causes and symptoms:

  1. A type of cellulite that is not visible when you stand up, but when you pinch the skin, it appears as wrinkles rather than dimples.
  2. Similar to the first stage except that if the skin is pinched, dimples will be visible instead of wrinkles. Toxins accumulate in adipose tissue, but have not yet entered the connective tissue.
  3. Toxins have accumulated in adipose tissue, and now they have pushed into the connective tissue, causing cellulite to become visible without even puckering the skin. Toxins are acidic and attract water to the area, causing fluid retention in problem areas. Circulation is poor and bruising often occurs.
  4. Cellulite begins to harden. It can be sensitive and painful because the buildup of tissue puts pressure on the nerve endings. Eliminating hard fibrous cellulite is very difficult.

In pharmacies and beauty salons you can find a sufficient number of creams for the later stages of cellulite. These products have a limited effect of tightening, toning or smoothing the skin, reducing the appearance of dimples.

Types of cellulite

Water Cellulite

Many women suffer from this type of cellulite: it occurs due to poor circulation and is usually accompanied by water retention. The texture of the skin is close to orange peel, the skin tissues are swollen, and the skin is uneven.

Adipose cellulite

This type is the easiest to get rid of because it usually occurs due to poor diet and a sedentary lifestyle. Adipose cellulite is visible only when a skin fold is formed or in certain positions and does not cause pain.

Fibrous cellulite

This type is the hardest to get rid of and get smooth skin. This type of cellulite is hard to the touch and can sometimes be painful to touch. Fibrous cellulite is noticeable and makes the skin uneven. Treating this type of cellulite will take a lot more time and effort.

How to prevent the appearance of cellulite

The causes are completely different, so you should think about how to prevent its appearance than after thinking about how to treat cellulite in its extreme stages.

However, following these simple tips can reduce the appearance of dimples.

  • Regular exercise.
  • A healthy diet high in fiber and low in salt, sugar and fat. On the other hand, cellulite is not related to weight, it is useless to follow a weight loss diet to prevent it.
  • Drinking plenty of water to avoid fluid retention in the body.
  • Avoid wearing clothes that are too tight around the legs and hips to improve circulation.
  • Take hot showers and baths.
  • End your shower with cold water to firm up your skin and increase blood circulation.

What to do if cellulite is no longer at the extreme stage

It is extremely important to add physical activity to your weekly routine, try to exercise at least twice a week. You can go for a walk, ride a bike or exercise at home, stretching will help get rid of toxins. All sweets and semi-finished products, as well as carbonated drinks and fruit juices, should be excluded from the diet. They can be safely replaced with tea, water with lemon juice and chopped fruit. Omega-3s can boost metabolism and reduce cell inflammation. Anti-cellulite cream will help to competently complete preventive procedures. Thanks to this, cellulite will become less noticeable.

There is currently no one-size-fits-all solution on how to treat cellulite in women. All methods boil down to improving its appearance, but will not help to remove it completely. Knowing your type will help you effectively begin the treatment of this scourge. Indeed, it is possible to establish effective strategies, such as certain diets and exercise regimes, that will help to remove the look of cellulite from the eyes. Regular exercise and a healthy, balanced diet can also help reduce overall appearance.

causes, signs, treatment, how to get rid of cellulite with massage, cream, brush

Causes

Symptoms

Stages

Types

Complications

Diagnosis

Treatment

Cellulite is a cosmetic defect in which the top layer of the skin resembles the skin of an orange. Tuberosity and irregularities are associated with a violation of the structure of the subcutaneous fat, a local increase in functional cells. The problem occurs against the background of changes in metabolism, hormonal imbalance, and requires an integrated approach to treatment.

Causes of cellulite

In medicine, cellulite is called lipodystrophy – a pathological change in subcutaneous fat. It occurs under the influence of various factors. In most cases, fat deposits in the thighs, abdomen and buttocks are the cause.

Cellulite changes the structure of connective tissue partitions separating cells of fat cells. There is a bulging of adipocyte papillae into the deep layers. Roughnesses, tuberosities are formed on the surface of the skin, microcirculation changes at the same time. This leads to stagnation of fluid, the appearance of edema and an increase in pressure inside the capillaries.

Among the main causes of cellulite:

  • hereditary factors, genetic disorders in the endocrine system;
  • diseases of the lymphatic and circulatory systems;
  • hormonal changes, decrease or increase in estrogen levels;
  • alcohol abuse, smoking and other bad habits that cause damage to the walls of blood vessels;
  • chronic lack of sleep, stress, sedentary lifestyle, slowing down metabolic processes;
  • wearing tight-fitting underwear and clothes that compress blood vessels, impede lymph flow.

Signs of cellulite on the abdomen or other parts of the body are diagnosed to varying degrees in 8 out of 10 women of reproductive age. Among the provoking factors: unbalanced diet, non-compliance with the drinking regimen, lack of regular physical activity.

In medicine, there are a number of diseases that increase the risk of developing cellulite in women:

  • hypothyroidism, thyroid dysfunction or tumors;
  • varicose veins;
  • renal failure, chronic pyelonephritis;
  • polycystic ovaries.

Cellulite in men can provoke obesity, a violation of the level of androgens.

Symptoms of cellulite

Characteristic signs depend on the stage of cellulite. At the initial stage, changes in the subcutaneous fat layer are almost invisible. Gradually, uneven skin appears, the epidermis becomes paler, the elasticity of the skin decreases.

In the absence of treatment and prevention of complications, the condition of blood vessels worsens, a vascular network is formed, and hemorrhages in adipose tissue may be observed. Often the problem is accompanied by the appearance of stretch marks and other cosmetic defects.

Cellulite stages

Pathological changes occur in several stages:

  1. Visual changes are not observed on the body. The papillary layer of the skin gradually thickens. In rare cases, microhemorrhages occur with the pressure of fat cells on the capillaries.
  2. Shallow dimples and bumps appear. They intensify when you try to collect the skin with your fingers. The epidermis becomes paler, the local temperature decreases, and “spider veins” appear.
  3. Cellulite on the legs and body is clearly visible with any movement, in the supine position. The skin loses its elasticity and smoothness. On palpation, the woman feels a slight pain. Visual examination shows signs of vasodilation, hemorrhage in the subcutaneous layer.
  4. Signs of cellulite on the thighs are clearly visible, large tubercles are fixed in the deep layer of the skin with the help of connective fibers, well palpable on palpation. The epidermis becomes thinner and atrophies, translucent small vessels. Microvaricose veins are often diagnosed.

The problem occurs not only in women after pregnancy or overweight. Increasingly, men and teenage girls are becoming patients of a dermatologist or cosmetologist.

Cellulite types

Depending on the symptoms, the following forms are diagnosed:

  • Hard cellulitis. It develops at almost any age, occurs among girls leading a healthy lifestyle. External manifestations are almost imperceptible, but when you try to make a fold on the thigh with your fingers, a characteristic tuberosity appears.
  • Flaccid cellulite. It occurs among obese people who do not pay attention to physical activity. It is provoked by a weakening of muscle tone, withering of the skin with a lack of moisture and proper nutrition. Symptoms are more pronounced, aggravated by sagging, the appearance of “spider veins”.
  • Edematous cellulitis. It is observed on the buttocks and thighs after weight gain. In the diagnosis, venous blood and lymph fluid stagnation is often observed. When pressed with a finger, a noticeable dent remains, indicating a violation of microcirculation. Women with this form of pathology often experience pain and stiffness in the lower extremities.

In rare cases, a mixed form is diagnosed. It combines symptoms of all kinds, is typical for women over 25-30 years old, manifests itself in any part of the body, including the forearm.

Possible complications of cellulite

In the absence of comprehensive care and therapy, the symptoms intensify, capillary damage develops, excess fluid accumulates, and edema occurs.

Possible complications of advanced cellulite:

  • acute inflammation of the subcutaneous fat;
  • circulatory disorders in the lower extremities;
  • formation of purulent phlegmon.

At the 3rd-4th stages of cellulite, qualified assistance from a cosmetologist or dermatologist is necessary.

Methods for the diagnosis of cellulite

During the initial examination, the specialist assesses the condition of the skin. To choose the right ways to remove cellulite, you need to evaluate the following indicators:

  • state of subcutaneous fat;
  • soft tissue density level;
  • signs of numbness or spasms;
  • decreased mobility of muscle tissue.

Patients must measure body volumes, calculate the mass index. Among the hardware diagnostic methods:

  • bioimpedance analysis to measure the level of electrical resistance in tissues;
  • magnetic resonance imaging (MRI);
  • computed tomography (CT);
  • thermography (shows areas with impaired heat transfer).

With cellulite of the 3rd-4th stages, an ultrasound examination of the vessels of the lower extremities is mandatory. It is important to assess the state of fiber, to identify varicose veins, the structure of connective tissue.

Cellulite treatment

When lipodystrophy appears, it is necessary to deal with the cause of the pathology. With flaccid and edematous cellulite, daily physical education, which tones the muscles, is recommended. It is important to correct body weight, reduce the amount of carbohydrates, sweets and other foods that provoke obesity in the diet.

At home, you can use a cellulite cream based on plant extracts, natural oils of orange, lemon.

Effective methods of restoring microcirculation and lymphatic drainage through cellulite massage and physiotherapy procedures:

  • using manual and vacuum techniques, vegetable oils;
  • LPG massage with special roller attachments;
  • pressotherapy – pneumatic massage, stimulating the outflow of lymph and drainage effect;
  • ultrasonic therapy that accelerates the breakdown of fat cells;
  • cavitation – non-invasive liposuction technique;
  • RF lifting.

An experienced cosmetologist will tell you how to get rid of cellulite without harm to health. Clinical treatment may include mesotherapy, ozone therapy, shock wave stimulation. It is necessary to speed up metabolism, restore metabolism.

At home, you can do a massage with a cellulite brush (but you should not forget about its thorough processing after each procedure), rub in a cream with a warming effect. Therapy is carried out in courses, diet and sports loads are prescribed at the same time.

To choose the right methods for getting rid of cellulite, you need to contact an experienced cosmetologist or dermatologist. If the problem appeared against the background of diseases of the gastrointestinal tract, thyroid gland, consultation and examination by an endocrinologist and gastroenterologist are recommended.

The author of the article:

Shapovalova Valeria Olegovna

cosmetologist, dermatologist, trichologist

work experience 7 years

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