Constitutional symptoms and response to Penicillin G in erysipelas and cellulitis - a monocentric, retrospective,...

Erysipelas, caused by streptococci, should be treated with penicillin, while uncomplicated cellulitis (phlegmon), often caused by Staphylococcus aureus, requires penicillinase-resistant beta-lactam antibiotics, which have a higher risk of adverse effects. Distinguishing between these infections is important. Constitutional symptoms like chills and fever may help in diagnosis. Therefore, we have compared retrospectively how frequently patients with erysipelas versus patients with cellulitis have experienced constitutional symptoms and whether they responded to penicillin.

We retrospectively evaluated patients with erysipelas or cellulitis admitted to the dermatology department of the university hospital Halle between January 2024 and January 2025. They had been managed according to an internal standard operation procedure for skin- and soft tissue infections.

Of 76 erysipelas patients without other infections, 91.4% reported constitutional symptoms at or before erythema onset, among them 17 of 18 patients with recurrent erysipelas. In contrast, only 36.2% of 47 cellulitis patients experienced such symptoms, typically later and not before erythema. Of patients with erysipelas, 98.3% responded within 2 days to penicillin, including 21 patients who had experienced symptoms for already 4 to 10 days prior to therapy.

Our findings suggest that early constitutional symptoms and characteristic erythema are reliable indicators for erysipelas. Erysipelas do not tend to heal promptly and spontaneously but respond reliably to penicillin.