Atypical Erysipelas With Serohematic Bullae and Necrosis: A Delayed Diagnostic and Therapeutic Challenge

Erysipelas is a superficial bacterial skin infection, most frequently caused by Streptococcus pyogenes, and typically presents with well-demarcated erythema, commonly affecting the lower extremities. Although usually responsive to early antibiotic therapy, atypical variants such as bullous erysipelas may complicate the clinical picture and delay appropriate management. We present the case of a 60-year-old woman with underlying comorbidities who developed a progressively worsening lower limb infection following minor trauma. The initial misdiagnosis and suboptimal antibiotic therapy contributed to clinical deterioration, including the formation of bullae and necrotic areas, raising suspicion for more severe infections. Despite negative cultures and biopsy results, clinical features supported the diagnosis of bullous erysipelas, which responded favorably to intravenous and oral β-lactam antibiotics. Long-term follow-up revealed persistent neuropathic pain, highlighting the potential for chronic sequelae even after resolution of the infection. This case emphasizes the need for early recognition of atypical erysipelas, timely initiation of appropriate antibiotics, and ongoing multidisciplinary management to address complications and optimize patient outcomes.