Differentiating erysipelas from other diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.


Erysipelas must be differentiated from other inflammatory dermatological conditions that present with pain, erythema, edema, and blisters of the skin, as well as other systemic conditions such as fever, chills, fatigue, headache, and vomiting.

Differentiating Erysipelas from other Diseases

Diseases Symptoms Signs Gold standard Investigation to diagnose
History Onset Pain Fever Laterality Scrotal swelling Symptoms of primary disease
(Cellulitis-erysipelas-skin abscess) Acute + + Unilateral - -
  • Usually it doesn't need any laboratory tests to diagnose.[2]
  • Blood cultures are warranted for patients in the following circumstances:[3]
  1. Systemic toxicity
  2. Extensive skin or soft tissue involvement
  3. Underlying comorbidities
  4. persistent cellulitis
Lymphatic filariasis
  • History of living in endemic area or travelling to it
Chronic + + Bilateral + -

Preparing blood smears

  • Thick smears
  1. Thick smears consist of a thick layer of dehemoglobinized (lysed) red blood cells (RBCs).
  2. Thick smears allow a more efficient detection of parasites (increased sensitivity).
  • Thin smears consist of blood spread in a layer such that the thickness decrease.

By the ultrasound, the following findings can be observed:

  • Dilated lymphatic channels
  • Living worms tend to be in motion which called "filarial dance" sign.
Chronic venous insufficiency Chronic + - Bilateral +

(If congenial)

  • Typical varicose veins
  • Skin change distribution correlate with varicose veins sites in the medial side of ankle and leg
  • Reduction of swelling with limb elevation.
Acute deep venous thrombosis Acute + - Unilateral - May be associated with primary disease mandates recumbency for long duration
Lipedema Chronic + - Bilateral - -
  • Tender with palpation
  • Negative Semmer sign to differentiate from lymphedema.[7]
  • Pinching the skin on the upper surface of the toes. If it is possible to grasp a thin fold of tissue then it is negative result.
  • In a positive result, it is only possible to grasp a lump of tissue.
  • MRI offers strong qualitative and quantitative parameters in the diagnosis of lipedema [8]
Myxedema Chronic + - Bilateral - +

(hypothyroidism )

Other causes of generalized edema
  • History of chronic general condition (cardiac-liver-renal)
Chronic - - Bilateral - +
  • According to the primary cause ( Echo- LFTs- RFT)
Disease Findings
Cellulitis Presents with nearly identical symptoms to erysipelas, and is also usually caused by Streptococcus or Staphylococcus bacteria.[10] Differentiated from erysipelas by its manifestation beneath the epidermis in the dermal layer of the skin; infection can spread to the subcutaneous fat, bones, joints, and muscles of the affected area. The area of inflammation is not as sharply visibly demarcated as those characteristic of erysipelas, due to the deeper manifestation in the skin. Can lead to complications with poor prognosis including osteomyelitis, lymphangitis, endocarditis, and meningitis.
Necrotizing fasciitis Presents with more severe epidermal signs and symptoms than erysipelas. Necrotizing fasciitis patients usually present with erythema, edema, blisters, pain, suppuration, and clear signs of tissue necrosis (dark violet/blue to black in appearance).[11] Left untreated, necrotizing fasciitis usually leads to subcutaneous nerve destruction; a patient communicating more pain than is visibly apparent or manifested on the epidermis is indicative of nerve damage preceding or disproportionate to visible evidence.[12] In addition to antibiotics, immediate therapeutic surgery is required to prevent morbidity from necrotizing fasciitis.
Shingles Presents with itching, pain, and tingling on a single side of the body or face, which will develop into a rash with blisters. It can also present with fever, chills, headache, and nausea.[13]. Differentiated from erysipelas by its cause (Varicella zoster virus infection) and is usually self-limited; antiviral therapy and analgesics are indicated to shorten the duration and severity of symptoms, which will usually self-resolve within 7-10 days. Recognition and diagnosis of shingles is important to prevent complications, including postherpetic neuralgia.[14]
Angioedema An edematous condition that involves swelling occurring below the epidermis, including the dermis and mucous membranes.[15] Angioedema usually presents with edema near the eyes and lips, as well as the hands, feet, and throat.[16] Can present similarly to erysipelas if epidermal welts and blisters form in the regions of edema, as well as cause abdominal pain.[17] Differentiated from erysipelas in that the cause is primarily an allergic reaction to a variety of possible allergens, including pollen, food, or medication. While angioedema is usually self-limited and will resolve itself upon the cessation of exposure to the allergen, treatment with antihistamines, epinephrine, or corticosteroids must be administered to prevent life-threatening complications, including asphyxiation if the edema occurs in the throat.[17]
Contact dermatitis An inflammatory condition of the epidermis resulting from direct contact with an allergen or irritant. Contact dermatitis is similar to erysipelas due to the usual presentation of erythema, blisters, itching, pain, and discharge. Differentiated from erysipelas by its cause: an allergic response by contact to a specific surface or entity. There is no indication of bacterial infection. Common causes include chemicals from cosmetic and hygienic products, fabrics, metals, and animal hair or skin. Therapy involves avoiding the original cause and application of topical or oral corticosteroids and analgesics.[18]
Inflammatory breast cancer Presents with edema and erythema of the breast, as well as itching, pain, and tenderness from the inflammation.[19] Differentiated from erysipelas by the fact that inflammation is usually limited to the breast. Additional differential criteria include development of "ridges" on the breast, giving the appearance of an orange peel. It is urgent to differentiate and diagnose inflammatory breast cancer to begin immediate chemotherapy, radiation therapy, and/or surgery when indicated.


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  19. "Inflammatory Breast Cancer - National Cancer Institute".

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