Erysipelas is an infectious disease caused by group A streptococcus, mainly affecting the skin and mucous membranes, characterized by the occurrence of limited serous or serous hemorrhagic inflammation, accompanied by fever and general intoxication. Clinically, erysipelas is characterized by a typical bright red edematous lesion of the skin, having clear boundaries and signs of lymphostasis. Complications of erysipelas include: formation of necrotic foci, abscesses and phlegmons, thrombophlebitis, secondary pneumonia, lymphedema, hyperkeratosis, etc.
Erysipelas is caused by beta-hemolytic streptococcus group A, most often of the type Streptococcus pyogenes, which has a diverse set of antigens, enzymes, endo- and exotoxins. This microorganism can be a component of the normal flora of the oropharynx, present on the skin of healthy people. The reservoir and source of rye infection is a person suffering from one of the forms of streptococcal infection, as well as a healthy carrier.
Erysipelas is transmitted by an aerosol mechanism mainly by airborne droplets, sometimes by contact. The entrance gate for this infection is damage and microtrauma of the skin and mucous membranes of the oral cavity, nose, genitals. Since streptococci often live on the surface of the skin and mucous membranes of healthy people, the risk of infection if the rules of basic hygiene are not followed is extremely high. The development of infection is facilitated by factors of individual predisposition.
Women get sick more often than men, susceptibility increases with prolonged use of drugs of the steroid hormone group. The risk of erysipelas is 5-6 times higher in people suffering from chronic tonsillitis and other streptococcal infections. Erysipelas of the face often develops in people with chronic diseases of the oral cavity, ENT organs, caries. The lesion of the chest and extremities often occurs in patients with lymphovenous insufficiency, lymphedema, edema of various origins, with fungal lesions of the feet, trophic disorders. Infection can develop in the area of post-traumatic and postoperative scars. There is some seasonality: the peak incidence occurs in the second half of summer – early autumn.
The pathogen can enter the body through damaged integumentary tissues, or if there is a chronic infection, it can penetrate into the capillaries of the skin with blood flow. Streptococcus multiplies in the lymphatic capillaries of the dermis and forms a focus of infection, provoking active inflammation or latent carrier. The active reproduction of bacteria contributes to the massive release into the bloodstream of their vital products (exotoxins, enzymes, antigens). The consequence of this is intoxication, fever, probably the development of toxic and infectious shock.
Erysipelas is classified according to several signs: by the nature of local manifestations (erythematous, erythematous-bullous, erythematous-hemorrhagic and bullous-hemorrhagic forms), by the severity of the course (mild, moderate and severe forms, depending on the severity of intoxication), by the prevalence of the process (localized, widespread, migrating (wandering, creeping) and metastatic). In addition, primary, repeated and recurrent erysipelas are distinguished.
Recurrent erysipelas is a recurring case in the period from two days to two years after the previous episode, or the relapse occurs later, but the inflammation repeatedly develops in the same area. Repeated erysipelas occurs no earlier than two years later, or is localized in a place different from the previous episode.
Localized erysipelas is characterized by the limitation of infection to a local focus of inflammation in one anatomical area. When the focus goes beyond the boundaries of the anatomical area, the disease is considered widespread. The addition of phlegmon or necrotic changes in the affected tissues are considered complications of the underlying disease.
The incubation period is determined only in the case of post-traumatic erysipelas and ranges from several hours to five days. In the vast majority of cases (more than 90%), erysipelas has an acute onset (the time of the appearance of clinical symptoms is noted to the nearest hour), fever develops rapidly, accompanied by symptoms of intoxication (chills, headache, weakness, body aches).
Severe course is characterized by the occurrence of vomiting of central genesis, convulsions, delirium. After a few hours (sometimes the next day), local symptoms appear: burning, itching, a feeling of bursting and moderate soreness when feeling, pressing appear on a limited area of the skin or mucous membrane. Pronounced pain is characteristic of erysipelas of the scalp. There may be soreness of regional lymph nodes during palpation and movement. Erythema and swelling appear in the area of the focus.
The peak period is characterized by the progression of intoxication, apathy, insomnia, nausea and vomiting, symptoms from the central nervous system (loss of consciousness, delirium). The area of the hearth is a dense bright red spot with clearly defined uneven borders (a symptom of “flames” or “geographical map”), with pronounced edema. The color of erythema can range from cyanotic (with lymphostasis) to brownish (with trophic disorders). There is a short-term (1-2 s) disappearance of redness after pressure. In most cases, densification, restriction of mobility and soreness are detected during palpation of regional lymph nodes.
Fever and intoxication persist for about a week, after which the temperature normalizes, regression of skin symptoms occurs somewhat later. Erythema leaves behind a finely scaly peeling, sometimes pigmentation. Regional lymphadenitis and infiltration of the skin in some cases may persist for a long time, which is a sign of a likely early relapse. Persistent edema is a symptom of developing lymphostasis. Erysipelas is most often localized on the lower extremities, followed by erysipelas of the face, upper extremities, and chest (erysipelas of the chest is most characteristic with the development of lymphostasis in the area of the postoperative scar).
Erythematous-hemorrhagic erysipelas is distinguished by the presence of hemorrhages from the local focus area against the background of general erythema: from small (petechiae) to extensive, draining. Fever in this form of the disease is usually longer (up to two weeks) and the regression of clinical manifestations is noticeably slower. In addition, this form of erysipelas can be complicated by necrosis of local tissues.
With erythematous bullous form, bubbles (bulls) are formed in the erythema region, both small and rather large, with transparent contents of a serous nature. Bubbles appear 2-3 days after the formation of erythema, are opened independently, or they are opened with sterile scissors. Bull scars with erysipelas usually do not leave. In the bullous-hemorrhagic form, the contents of the vesicles are serous-hemorrhagic in nature, and, often, are left after opening erosion and ulceration. This form is often complicated by phlegmon or necrosis, after recovery, scars and areas of pigmentation may remain.
Regardless of the form of the disease, erysipelas has features of the course in different age groups. In old age, primary and repeated inflammation is usually more severe, with an extended period of fever (up to a month) and an exacerbation of existing chronic diseases. Inflammation of regional lymph nodes is usually not noted. The clinical symptoms subside slowly, relapses are not uncommon: early (in the first half of the year) and late. The frequency of relapses also varies from rare episodes to frequent (3 or more times per year) exacerbations. Recurrent erysipelas is often considered chronic, while intoxication often becomes quite moderate, erythema has no clear boundaries and is paler, the lymph nodes are not changed.
The most common complications of erysipelas are suppuration: abscesses and phlegmons, as well as necrotic lesions of the local focus, ulcers, pustules, inflammation of the veins (phlebitis and thrombophlebitis). Sometimes secondary pneumonia develops, with a significant weakening of the body, sepsis is possible.
Long-term stagnation of lymph, especially in the recurrent form, contributes to the occurrence of lymphedema and elephantiasis. Complications of lymphostasis also include hyperkeratosis, papillomas, eczema, and lymphorrhea. Persistent pigmentation may remain on the skin after clinical recovery.
Diagnosis of erysipelas is usually carried out on the basis of clinical symptoms. To differentiate erysipelas from other skin diseases, you may need to consult a dermatologist. Laboratory tests show signs of bacterial infection. As a rule, specific diagnostics and isolation of the pathogen are not performed.
Erysipelas is usually treated on an outpatient basis. In severe cases, with the development of purulent-necrotic complications, frequent relapses, in old age and early childhood, placement of the patient in a hospital is indicated. Etiotropic therapy consists in prescribing a course of antibiotics of the cephalosporin series of the first and second generations, penicillins, some macrolides, fluoroquinolones lasting 7-10 days in average therapeutic dosages. Erythromycin, oleandomycin, nitrofurans and sulfonamides are less effective.
With frequent relapses, sequential administration of two types of antibiotics of different groups is recommended: after beta-lactams, lincomycin is used. Pathogenetic treatment includes detoxification and vitamin therapy, antihistamines. With bullous forms of erysipelas, bubbles are opened and often replaced gauze napkins with antiseptic agents are applied. Ointments are not prescribed in order not to irritate the skin once again and not slow down healing. Topical preparations may be recommended: dexpanthenol, silver sulfadiazine. Physiotherapy (UHF, UVI, paraffin, ozokerite, etc.) is recommended as a means to accelerate the regression of skin manifestations.
In some cases of recurrent forms, patients are prescribed courses of anti-relapse treatment with benzylpenicillin intramuscularly once every three weeks. Persistently recurrent erysipelas is often treated with courses of injections for two years. If there are residual phenomena after discharge, patients may be prescribed a course of antibiotic therapy for up to six months.
Erysipelas of a typical course usually has a favorable prognosis and, with adequate therapy, ends in recovery. A less favorable prognosis occurs in the case of complications, elephantiasis and frequent relapses. The prognosis also worsens in weakened patients, elderly people, people suffering from vitamin deficiency, chronic diseases with intoxication, digestive disorders and lymphovenous apparatus, immunodeficiency.
General prevention of erysipelas includes measures for the sanitary and hygienic regime of medical institutions, compliance with the rules of asepsis and antiseptics in the treatment of wounds and abrasions, prevention and treatment of pustular diseases, caries, streptococcal infections. Individual prevention consists in observing personal hygiene and timely treatment of skin damage with disinfectants.