Cellulitis

Cellulitis overview

Cellulitis is a dermal infection that occurs when bacteria enters the body through a break in the skin. This could simply be from dry skin that has cracked, but can also be related to a wound, ulcer, surgical incision, fungal infections of the feet, bug bite, or dermatitis. Cellulitis is usually localized to the skin, but it can spread into the bloodstream and lead to sepsis, which is a life-threatening condition. Other complications of cellulitis include osteomyelitis, endocarditis, joint infection, thrombophlebitis, and tissue necrosis. 

The most common pathogen responsible for cellulitis is group A streptococcal bacteria. However, the incidence of MRSA is increasing, which is an infection caused by methicillin-resistant Staphylococcus aureus.

In addition to having a skin injury, risk factors for cellulitis include lymphedema, immunosuppression, venous insufficiency, obesity, and chronic skin conditions such as eczema. Note that patients who’ve undergone a coronary artery bypass graft often develop lymphedema in the leg where the bypass vein was harvested.

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L:  How does the patient LOOK?

In cellulitis, the area of inflammation is often surrounding a break in the skin that has allowed bacteria to enter. The skin is red, swollen, warm, dimpled or “orange peel” in texture, and painful to the touch. The area of inflammation typically has a definable border and when the infection spreads you may see red streaks in the skin as well as enlarged lymph nodes.

Cellulitis usually affects the lower legs, but it can occur anywhere on the body. Note that cellulitis is generally unilateral, meaning it doesn’t affect both extremities at the same time. Patients with cellulitis usually also have a fever and feel generally unwell (malaise).

A: How do you ASSESS the patient?

Assessments for cellulitis include:

• Monitor vital signs – The patient will usually have a fever and may also have an elevated heart rate (tachycardia). If sepsis occurs, the patient will experience hypotension as the body mounts an overwhelming immune response to the infection.
• Assess pain – The pain with cellulitis is localized to the area of inflammation. The patient may find that bedding or clothing touching the skin is irritating.
• Assess the skin for warmth, tenderness, and swelling. In some cases blisters may occur. 
• Monitor the size of the affected area – Use a marker to outline the infection so its expansion is easy to notice.

T: What TESTS are used to evaluate cellulitis?

Diagnostic evaluation of cellulitis generally involves examination of the skin. Additional tests utilized for a patient with cellulitis include:

• WBC – will be elevated
• CRP and/or ESR – elevated in inflammatory states
• Lactate – a lactate level will be measured if sepsis is suspected
• Wound culture – if a purulent wound is present, a culture can determine the specific pathogen so antibiotics can be highly targeted. However, skin cultures in non-draining wounds have not been found to be helpful in cellulitis so are not generally utilized.
• Ultrasound – In some cases, cellulitis of the lower leg may mimic a DVT. An ultrasound may be conducted to rule out a deep vein thrombosis.
• X-ray – Diagnostic imaging may be utilized to determine if the infection has spread into the bone, a condition called osteomyelitis.

T: What TREATMENTS are utilized for cellulitis?

Most cases of cellulitis can be treated at home, though severe cases with complications may require hospitalization. Treatment for cellulitis includes:

• Antibiotics are usually administered PO, but in severe cases the patient may need IV antibiotics.
• NSAIDs to reduce inflammation and pain. Acetaminophen may also be added if NSAIDs are not sufficient in treating pain.
• Elevate the affected area. This helps reduce edema and pain.
• Cool, clean washcloths applied to the skin can help reduce edema and pain.

E: How do you EDUCATE the patient/family?

Key things to teach regarding cellulitis include:

• Cellulitis is not contagious, but the MRSA bacteria (if present) can spread person-to-person and through the sharing of personal items such as towels.
• To prevent cellulitis when a wound occurs, keep it clean and cover with a bandage. In some cases, an ointment such as Vaseline can provide barrier protection to prevent bacteria from entering the body.
• Apply lotion to dry or cracked skin to help it heal.
• Watch for signs of worsening infection such as increased area of redness, increased pain, development of blisters and/or purulent drainage, streaking, enlarged lymph nodes, and fever.
• Individuals with impaired circulation or diabetes should inspect their feet daily, keep feet clean and moisturized, wear socks and closed-toe shoes, and dry skin thoroughly after bathing (especially between the toes).
• Patients with lymphedema can prevent cellulitis by wearing compression sleeves.

Review cellulitis on the go in episode 362 of the Straight A Nursing podcast wherever you listen to podcasts, or from right here.

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References:

CDC. (2024, May 22). About Cellulitis. Group A Strep Infection. https://www.cdc.gov/group-a-strep/about/cellulitis.html

Epomedicine. (2020, February 22). Cellulitis vs Early Osteomyelitis. Epomedicine. https://epomedicine.com/clinical-medicine/cellulitis-vs-osteomyelitis/

Harvard Health. (2024, May 21). Cellulitis. Harvard Health. https://www.health.harvard.edu/a_to_z/cellulitis-a-to-z

Johns Hopkins Medicine. (2019, November 19). Cellulitis. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/cellulitis

Kenney, A., & Kling, R. (2020). Dermatologic Pain. In EMRA Pain Management Guide (1st ed.). EMRA. https://www.emra.org/books/pain-management/dermatologic-pain

Mayo Clinic. (2022, May 6). Cellulitis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/cellulitis/symptoms-causes/syc-20370762

Sepsis Alliance. (2023). Sepsis and cellulitis. Sepsis Alliance. https://www.sepsis.org/sepsisand/cellulitis/

Last Updated on August 29, 2024 by Maureen Osuna, MSN, RN