MKSAP Quiz: Evaluation for erythema and tenderness
A 71-year-old man is evaluated for erythema and tenderness of the left lower leg for 1 week's duration. This is the second similar episode of the left lower leg. The last episode was 2 months ago. He was previously treated successfully with antibiotics. Following tissue findings on a physical exam and starting antibiotics, what is the most appropriate management?
A 71-year-old man is evaluated for erythema and tenderness of the left lower leg for 1 week's duration. This is the second similar episode of the left lower leg. The last episode was 2 months ago. He was previously treated successfully with antibiotics.
On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 125/75 mm Hg, respiration rate is 16/min, and pulse rate is 85/min. There is a well-demarcated, warm and tender erythematous patch on the anterior lower left leg extending from dorsal foot to mid shin. There is tissue maceration and fissuring between second and third toe spaces bilaterally. The remainder of the physical examination is normal.
In addition to initiating antibiotic therapy, which of the following is the most appropriate management?
A. Following acute therapy, start prophylactic antibiotics
B. Obtain blood cultures
C. Obtain skin punch biopsy
D. Staphylococcal decolonization with intranasal mupirocin
E. Treat the interdigital intertrigo
MKSAP Answer and Critique
The correct answer is E. Treat the interdigital intertrigo. This content is available to MKSAP 18 subscribers as Question 20 in the Dermatology section. More information about MKSAP is available online.
The most appropriate management of this patient is to treat the interdigital intertrigo. The diagnosis of cellulitis often is made based on the clinical presentation of a well-demarcated warm and tender erythematous plaque. Bacteria enter through superficial breaks in the skin or gain access by hematogenous spread. Treatment of the maceration and fissuring in the toe web spaces can decrease the risk of recurrent cellulitis. This fissuring, maceration, and scaling are often due to tinea pedis, which allows entry for Streptococcus and Staphylococcus aureus to infect the lower extremity. In addition, attempts should be made to identify and treat other predisposing conditions for cellulitis, such as edema, obesity, eczema, and venous insufficiency.
Because this is only the second episode of cellulitis for this patient, prophylactic antibiotics are inappropriate. There has been no attempt to address predisposing factors. Prophylactic antibiotics can be considered when a patient has three to four episodes of cellulitis per year. Treatment is usually with oral penicillin or erythromycin. Attempts to treat predisposing factors such as edema, obesity, venous insufficiency, and toe web abnormalities should be addressed first.
Blood culture is not recommended for cellulitis unless a patient has a malignancy and is on chemotherapy, or has neutropenia, severe immunodeficiency, an immersion injury, or an animal bite. This patient has none of these indications.
The patient has a classic presentation of cellulitis, and obtaining a skin biopsy is not necessary.
Staphylococcal decolonization with intranasal mupirocin can be considered for recurrent skin abscesses, but it is not effective for recurrent cellulitis.
Key Point
- Evaluation of the interdigital toe spaces and treatment of the maceration and fissuring in the web spaces and modification of other predisposing factors such as edema, obesity, eczema, and venous insufficiency can decrease the risk of recurrent cellulitis.