Clinical REVIEW Clinical REVIEW Lower limb cellulitis: a dermatological perspective

Skin disease such as venous eczema and tinea pedis are often overlooked as primary causes of lower limb cellulitis. This article will look at the management of these two common skin conditions as well as the diagnosis and management of lower limb cellulitis. Kilburn et al (2003) acknowledge that the treatment of cellulitis is multiciplinary stating that no one speciality can claim the condition as their field and the Clinical Resource Efficiency Support Team (CREST, 2005) recommend that key staff in an integrated cellulitis pathway should include dermatologists. The article will give details of a dermatology- led lower-limb cellulitis service which demonstrates a best practice initiative which avoids unecessary hospitalisation, incorrect diagnoses and also helps to reduce the risk of recurrent cellulitis.

Carrie Wingfield

Kilburn et al (2003) acknowledge the KEY WORDS treatment of cellulitis as multidisciplinary Dermatology stating that no one speciality can Lower limb cellulitis claim the condition as their field. Dermatologists often receive tertiary Venous eczema referrals to see patients who have been Tinea pedis treated as inpatients on acute medical/ Service provision surgical wards for lower limb cellulitis. On examination it is not uncommon to find a differential diagnosis of infected venous eczema (Figure 2), or undiagnosed Figure 1. Example of lower limb cellulitis. ellulitis currently accounts for tinea pedis (Figure 3). The consequence 2–3% of hospital admissions of these skin disorders being overlooked C(Cox et al, 1998) and is an acute, or misdiagnosed and the subsequent painful and potentially serious infection need to treat patients for cellulitis can of the skin and subcutaneous tissue result in unnecessary admissions, use of (Figure 1), usually involving pathogens hospital bed bays, pressure on emergency Staphylococcus aureus and Streptococcus medicine resources and the use of pyogenes. The average length of inpatient inappropriate intravenous antibiotic stay for cellulitis is 7.1 days (Department therapy. Admission to hospital can be of Health [DoH], 2009), a total of daunting and unsettling and could also 30,524 bed days in 2007–2008. These place the patient at risk of hospital- figures do not differentiate which part acquired infections and increased risk of of the body is affected, but evidence antibiotic resistance (Wingfield, 2008). suggests that lower limb cellulitis is the most prevalent (Cox et al, 1998; Both venous eczema and tinea pedis Halpern et al, 2008). Further episodes of are recognised as risk factors for the treatment for patients with lower limb opportunistic development of lower Figure 2. Infected venous eczema with yellow cellulitis show that 25–50% have other limb cellulitis. Venous eczema, sometimes crusting (impetiginisation). associated morbidity, such as oedema, called stasis eczema or varicose eczema is ulceration and skin disease (Cox et al, linked to secondary venous hypertension. inflammation and induration called 1998; Dupuy et al, 1999). It is often associated with varicose veins, lipodermatosclerosis. The eczema can be although they are not always present. more prominent when coexisting with Carrie Wingfield is Clinical Lead Senior Nurse Manager Clinical presentation includes pitting venous ulcers (Holden et al, 2004). Tinea Dermatology and Honorary Lecturer, University of East oedema, stasis purpura resulting in pedis is a fungal infection presenting mostly Anglia, Norfolk and Norwich University Foundation Hospital haemosiderin deposits, dry itchy skin, in the interdigital toe web spaces. It is often

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Table 1 Comparison of clinical features of varicose (venous) eczema and cellulitis of the leg adapted from Quartey-Papafio (1999)

Eczema Cellulitis Symptoms Apyrexial May have pyrexia Itching Painful Figure 3. Tinea pedis. History of varicose veins or deep No relevant history vein thrombosis (DVT) Signs Erythematous, inflamed Erythematous, inflamed No tenderness Tenderness Vesicles One or a few bullae Crusting No crusting Other lesions on body No other lesions Portal of entry Not applicable Usually unknown but may be ulceration or associated skin disease such as eczema or tinea pedis Investigations White blood count normal White blood count high Blood culture negative Blood culture usually negative Skin swabs — S. aureus common Skin swabs usually negative except for necrotic tissue

to differentiate cellulitis from other dermatological and vascular diagnoses (Quartey-Papafio, 1999; Cox, 2002). Others have concluded that 29% of patients develop recurrent lower limb cellulitis within a mean of three years after Figure 4. Venous leg ulcer with secondary cellulitis. the first episode (Jorup-Ronstrom and Britton, 1987). This is frequently associated asymptomatic and is commonly caused with existing venous insufficiency with by Trichophyton rubrum, T. mentagrophytes developing or existing venous eczema and Epidermophyton floccosum. Hands and/or venous ulcers which also increase and toenails may also be involved. Clinical the prevalence of cellulitis episodes presentation includes scaling, maceration, (Jorup-Ronstrom and Britton, 1987) fissuring and erythema in the interdigital (Figure 4). These conditions are recognised area (Fleischer et al, 2002). If these skin as risk factors for the entry of ‘infective conditions are diagnosed and treated organisms’ (Dupuy et al, 1999). Cox et al’s Figure 5. Lipodermatosclerosis. appropriately, there is both a possibility of (1998) retrospective study identified skin the two conditions in a simple table reducing this risk of developing cellulitis disease/broken skin in 51/92 patients, the (Table 1). This table is a useful assessment and experiencing recurrent cellulitis most common being minor trauma and tool when assessing the lower limb episodes which can lead to chronic tinea pedis. This study was conducted as for suspected cellulitis. The absence of oedema. The key objective of this article an audit and held across two hospitals. It pain is a good indicator that there is is to heighten awareness of the diagnosis, looked at the case notes of 92 patients no subacute soft tissue infection. From treatment, management and investigation admitted with a diagnosis of lower limb clinical experience, any applied pressure of these common skin conditions as cellulitis under different adult specialities. It or handling of a leg with cellulitis is often part of the assessment and diagnosis of also concluded that pathogens were rarely acutely tender and painful for the patient suspected lower limb cellulitis. identified. and they will frequently have difficulty bearing weight on the affected leg. Recognising and treating skin disease Quartey-Papafio (1999) identified Although some discomfort is noted in associated with lower limb cellulitis the issue of misdiagnosis and confusion infected venous eczema, the pain would Venous eczema of cellulitis and venous eczema and not be acute and mobility should not It is extremely important to be able highlighted the clinical difference between be affected unless the patient had other

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7a Figure 6. Atrophy blanche.

painful coexisting conditions, for example ischaemia, ulceration or lymphoedema. Figure 8. Contact dermatitis — the identifi ed It is important to note that infected allergen in this case is a paste bandage containing venous eczema and cellulitis can present parabens. together. as corticoid steroids, emollients and When diagnosing venous eczema the dressings. Some patients may need following signs can be clinically indicative: 7b intensifi ed treatment application to bring 8 Varicose veins/deep vein thrombosis the eczema under control. Assessment 8 Lipodermatosclerosis (Figure 5), a Figures 7a and 7b. Gravitational eczema would include exclusion of cellulitis, pain, localised chronic infl ammation of the (autoeczematisation/Id reaction). skin integrity, choice and implementation skin and subcutaneous tissues — a sign of topical or systemic therapy. Daily of severe chronic venous disease and topical steroids (Quartey-Papafi o, application may be required, in particular 8 Atrophy blanche (Figure 6) 1999; Smith, 2006; Middleton, 2007). if the legs are weeping and dressings have 8 Infection may be evident by Infl amed lipodermatosclerosis has a slow been necessary or if the patient is not yellow crusting or small vesicles response to topical treatments and may able to apply their topical treatments. If (impetiginisation) (Figure 2) require use of very potent topical steroids a moderate-to-potent steroid has been 8 Hyperpigmentation — skin darkens in (Duffi ll, 2008). It is not uncommon for used a review will be required to step colour contact dermatitis to present with venous down the strength according to response. 8 Gravitational eczema eczema (Figure 8). The literature shows If there is coexisting leg ulceration, (autoeczematisation Figures 7a and that patients with chronic venous leg redressing of the ulcer may have to be 7b). This condition sometimes occurs ulcers are more prone to sensitisation increased in the short term to access the when venous stasis eczema is present to topical applications such as creams/ eczema and treat accordingly. on the lower legs. The eczema can ointments, primary dressings and bandages spread to other parts of the body as (Barron et al, 2007; Middleton, 2007). There is little evidence to support the an autosensitisation reaction use of topical antiseptics. The National 8 Family history of venous disease, There is insuffi cient evidence on the Institute for Health and Clinical Excellence history of leg ulceration. Existing or use of compression stockings in treating (2007) recommends that these products healed leg ulcer. venous eczema and lipodermatosclerosis. can be used as adjunct therapy to reduce The general view is that compression bacteria levels on the skin. It advises that Examine the rest of the body as plays an important role in reducing topical and systemic antibiotics should not untreated venous eczema may gravitate venous hypertension, therefore improving be used where no clinical signs of infection to the upper thighs, trunk and upper limbs, and slowing down skin changes which are observed. a phenomenon known as gravitational may contribute to venous eczema. Leg eczema (autoeczematisation/Id reaction). elevation and exercise can improve Tinea pedis The rash often occurs at a site distal to the venous return and reduce venous Tinea pedis, also known as athlete’s original onset. The existing venous eczema pressure and this may help to improve foot (Figure 3), is a dermatophyte on the lower leg acts as a stimulus causing the skin. However, there is no trial infection and is recognisable as a a reaction to the body’s immunological evidence regarding the benefi ts of these curable, dermatological primary cause of response (Evans and Bronson, 2009). interventions (Wounds UK, 2002; Partsch, recurrent lower limb cellulitis, but is rarely 2003; Barron et al, 2007; Duffi ll, 2008). diagnosed in clinical areas other than Assessment and treatment of venous eczema, dermatology (Pierce and Daugird, 1992). gravitational eczema and lipodermatoslerosis The management of infected venous Tinea pedis affects the interdigital web The pathophysiology of venous eczema is eczema will require skin assessment space, commonly between the fourth not clear. It is classed as an infl ammatory and interventions involving frequent and fi fth toe. Cox et al (1998) conclude dermatoses that responds to emollients applications of topical treatments such that the treatment and diagnosis of tinea

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Table 2 Management and assessment of infected venous eczema (adapted from NICE, 2007)

Characteristics 8 Weeping, crusting pustules 8 Failure to respond to treatment 9a 8 Worsening eczema 8 Fever/malaise Interventions/ 8 Wash skin with a suitable soap substitute at each investigation dressing change 8 Antiseptic emollients can be useful Medications/treatments 8 Daily topical treatment and assessment may be required 8 Assess and document the extent of skin surface affected 9b 8 If extensive, swab skin and prescribe fi rst-line antibiotics 8 If the infection responds poorly to antibiotic treatment, consider Figure 9a. Dermapak® and size 15 blade for results of the swab and treat according to sensitivities, or seek distribution of tinea pedis. Figure 9b. Fungal specialist advice toenails and moccasin skin scrapings/toenail 8 If there are localised areas of infection, consider prescribing a topical clippings. antibiotic 8 Creams or ointments containing antibiotics can be used as separate products or combined with a corticosteroid 8 Maceration 8 Advise that the ointments should be used for no longer than 7–14 days 8 Fissuring. and should not be used as a stand-alone therapy for more extensive infected eczema Diagnostic investigations for athlete’s foot or other fungal skin infections are not Maintenance 8 If not already performed, assess arterial circulation, ankle brachial pressure index (APBI) using a hand-held Doppler always required if the presenting clinical 8 If the APBI is >0.8, consider compression hosiery once infected eczema picture is clear. Recommendations are to has been treated. APBI should be considered with the patient’s history take skin scrapings for microscopy and and other comorbidties as part of the decision process. If it is <0.8, culture if the diagnosis is not clear, the skin refer the patient to a vascular surgeon has not improved or has deteriorated 8 Class 2 (medium) hosiery suits most people. Use class 1 (light) if not with standard topical treatment, or if oral tolerated. Class 3 (high) may be diffi cult to tolerate antifungal medication is indicated as fi rst- 8 Consider topical skin regimen that patient or carers may be able line treatments have failed or condition is to continue and sustain and educate the patient about the signs of becoming more widespread (Loo, 2004; infection/cellulitis Andrews and Burns, 2008). It should Evaluation 8 If not responding to treatment, refer to swab results for antibiotic be highlighted that microscopy/culture sensitivity results from scrapings and clippings can 8 If the condition deteriorates despite correct antibiotic therapy, consider take a few weeks to come back. There contact dermatitis or inadequate control and refer the patient to a is also a signifi cant false-negative rate dermatologist for microscopy and culture. Therefore, a 8 Reassess ongoing management with topical treatment tailored to the negative result does not always exclude individual 8 Issue new topical treatment supplies after the infection is fungal infection and the diagnosis may treated and discard old treatment to avoid the possibility of cross- need to be made clinically if signs are contamination by old supplies signifi cant (Higgins et al, 2000).

Tinea pedis can become more extensive affecting the plantar and dorsum pedis in combination with treatment caused by trichophyton, microsporum, surface of the foot; lateral borders of chronic oedema, for example with and epidermophyton species. Tinea pedis can also be involved giving a moccasin compression, can reduce subsequent is most commonly due to T rubrum, but distribution. Fungal toenails (Figure 9b) are cellulitis episodes. This supports the need also caused by T interdigitale (Clinical sometimes evident and were thought to for dermatologist input within a lower Knowledge Summary, 2008a). Clinical be commonly associated with tinea pedis. limb cellulitis pathway (Wingfi eld, 2008). signs are: However, evidence involving a large study 8 Itching of patients with tinea pedis (n=5,143) Dermatophytes are fungi that can 8 Burning showed that only 20% of patients were cause infections of the skin, hair, and nails. 8 Irritation over site found to have coexisting fungal toenails Common dermatophyte infections are 8 Skin scaling (Burzykowski et al, 2003).

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Treatments Table 3 8 Advise good foot hygiene to patient/ Presentation/management of lower limb cellulitis carer/nurse and ensure that they dry thoroughly between the toes after washing 8 Treat with a topical imidazole, Clinical presentation undecenoate, or terbinafine. Imidazoles: Risk factors Symptoms treat for 2–4 weeks to clear the Obesity Spreading erythema (redness) lesions. Terbinafine (adults only): treat Lymphoedema Painful, tender skin for 1–2 weeks to clear the lesions. Diabetes Hot, swollen Undecenoates (adults only): treat for Venous disease/ulceration Blister or bullaeo Previous episodes of cellulitis Pyrexia 2–4 weeks to clear the lesions Immunocompromised Malaise, nausea, rigors 8 Continue topical treatment for 1–2 Intravenous drug users Lymphangitis/lymphoedema (Figure 10) weeks after the skin has healed 8 Preparations combining a topical Diagnosis/clinical assessment anti-fungal agent with corticosteroid Consider differentials Identify primary cause if possible are usually unnecessary. Consider Swab if there is an obvious portal of bacterial entry doing this if the infection is particularly Mark any tracking erythema with a skin marker inflamed and irritated Take baseline observations (refer on if there are two or more signs of sepsis) 8 Failure to respond to treatment Biochemistry: the following blood tests although none specific are nearly always elevated in patients and if the condition becomes more with cellulitis — ESR (erythrocyte sedimentation rate), CRP (C-reactive protein) and WBC (which extensive may indicate a need for blood cell count). Normal results make a diagnosis of cellulitis less likely systemic treatment. Consider referring Check lymph glands. They may be swollen, tender the patient to a dermatologist. Determine or initiate investigation or referral if differential diagnosis Take patient history, date of onset, first or recurrent episode of lower limb cellulitis Lower limb cellulitis — diagnosis Medications, past history, allergies, social circumstances and management Intervention (Class I) Cellulitis is an acute bacterial infection If diagnosed as lower limb cellulitis and systemically well, commence high-dose oral antibiotic for 7 days of the dermis and subcutaneous tissues, Treatment: primary care and typically affects one limb and is rarely Flucloxacillin (500mg qds) bilateral (Swartz, 2004) (Figure 10). It Erythromycin (500 mg qds) — if allergic to penicillin is important to make a diagnosis and Clarithromycin (500mg bd) — if erythromycin not tolerated exclude other differentials such as: Consider adding on a second antibiotic if the cellulitis has arisen from a wound contaminated with 8 Deep vein thrombosis water: doxycycline (100mg once a day) for saltwater contamination; ciprofloxacin (750mg twice a day) 8 Infected venous eczema for freshwater contamination (usually bilateral) Treat any co-existing skin condition, venous eczema, tinea pedis Advise on appropriate analgesia if required 8 Erythema nodosum Advise to drink plenty of water to avoid dehydration 8 Pyoderma gangrenosum Leg elevation to ease pain and help reduce swelling 8 Vasculitis 8 Necrotising fasciitis Review 8 Ask patient to contact if symptoms deteriorate in the next seven days Gangrene Plan and organise a review appointment to monitor progress 8 Acute gout Assess skin and any treated skin condition 8 Drug reactions Monitor erythema markings on review. If erythema is below the original line it is a useful indicator 8 Metastastic cancer. that the infection is subsiding. If erythema is spreading above the original line consider referral to secondary care Assess the limb for possible primary Repeat baseline observations cause, for example: Doppler if compression is to be considered and cellulitis resolved 8 Venous eczema If the patient has deteriorated consider referral to secondary care 8 Tinea pedis If resolved educate patient to possible cause, and educate to recognise signs and symptoms of 8 Trauma recurrence and to avoid injury, burns and bites 8 Ulcerations Referral class II–III refer to Refer to secondary care for: 8 Burn/bites. secondary care Systemically unwell/toxic symptoms Complex comorbidities Further investigation Take a swab for bacteriology if Failure to respond to treatment Uncertain/differential diagnosis appropriate. Admission Intravenous therapy Assessing the severity of the cellulitis is important as the presence and signs of

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systemic symptoms may indicate sepsis or osteomylitis which could lead to a speedy deterioration in the patient’s condition. Key Points Patients with two or more signs of sepsis should not be managed in primary care 8 Cellulitis accounts for 2–3% of all and will require hospital assessment and hospital admissions. admission. Signs of septicaemia include: 8 Pyrexia 8 Recurrent episodes of lower 8 Tachycardia limb cellulitis can be associated 8 Increased respiration with primary skin disease such as 8 Elevated white blood cell count venous eczema and tinea pedis 8 Hypotension and it is important to treat these 8 Reduced urine output conditions appropriately when 8 Diarrhoea they are first encountered. 8 Cold/clammy Figure 10. Lower-limb cellulitis with 8 Confusion/disorientation. associated lymphoedema. 8 Venous eczema is often misdiagnosed and treated Table 3 outlines assessment process, systemic symptoms and can be managed as cellulitis. intervention, treatment and recommended with oral antibiotics (CREST, 2005). 8 The treatment of cellulitis is review for lower limb cellulitis. Refer to secondary care if diagnosis is not clear or the patient has already multidisciplinary and benefits from the involvement of Grading is recommended using received first-line antibiotics and is dermatologists. a classification system from class I–IV deteriorating. Other comorbidities may (Eron, 2000) (Table 4). Only patients complicate the diagnosis and delay healing. with Class I cellulitis should remain in These multiplex cases should also be primary care. These patients would considered for referral to secondary are high-risk candidates for recurrent have no uncontrolled comorbidities or care. Consider routine referral if the cellulitis due to local immune deficiency patient is experiencing recurrent episodes (Dupuy et al, 1999). of lower limb cellulitis with associated Table 4 lymphoedema (Figure 10). Suggested service provision Grades of cellulitis (Eron, 2000; CREST, 2005) and development Lymphoedema There is limited evidence-based Recommendations vary for antibiotic research supporting dermatology as an therapy in the management of cellulitis appropriate specialist team to manage Class I with lymphoedema. The British uncomplicated lower limb cellulitis. Patients have no signs of systemic toxicity, have Lymphology Society (BLS) recommends However, in the available published no comorbidities and can usually be managed prophylactic antibiotic treatment for work, dermatology is highlighted as with oral antimicrobials as outpatients. patients who have two or more attacks being a necessary cohort of expertise a year. They have published a consensus in the diagnosis and management of this Class II document giving concise guidance on condition (CREST, 2005). Patients are either systemically ill or management and treatment (British systemically well but with a comorbidity such Lymphology Society and Lymphoedema The common scenario already as peripheral vascular disease, chronic venous Support Network, 2007). mentioned of patients sitting in hospital insufficiency or morbid obesity which may beds with a misdiagnosis of cellulitis complicate or delay resolution of their infection. Following an episode of cellulitis of has become a key driver for service the leg evidence suggests 7% of patients development in one dermatology Class III go on to develop chronic oedema department in Norwich. Previously, Patients may have a significant systemic upset (lymphoedema), known as secondary the majority of cellulitis referrals came such as acute confusion, tachycardia, tachypnoea, lymphoedema (CREST, 2005). The cellulitis through either the Emergency Assessment or may have unstable comorbidities that may infection causes damage to a previously Medicine Unit (EAUM) or A&E. interfere with a response to therapy, or have fully functioning lymphatic system. A recent Tertiary referrals would come into the a limb-threatening infection due to vascular hypothesis suggests a predisposition dermatology department for opinion on compromise. to cellulitis in patients with previous rashes or ulcerations for patients admitted unpresenting, undiagnosed primary to hospital for intravenous therapy. Class IV lymphatic abnormality. The cellulitis then Both the dermatologist and emergency Patients have sepsis syndrome or severe life- causes further damage and symptoms medicine team realised that patients with threatening infection such as necrotising fasciitis. become apparent (Keeley, 2008). Patients lower limb cellulitis were missing out on with primary or secondary lymphoedema quick diagnosis of primary skin disease and

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late differential diagnosis was delaying the patient’s pathway of care.

As a direct consequence of this a new same-day referral outpatient cellulitis clinic was set up in the dermatology outpatients department (Wingfield, 2008). GPs using a criteria, can refer lower limb cellulitis cases to this clinic where a thorough assessment is carried out to include diagnosis/ treatment/investigation of any differential diagnosis or coexisting skin disease. The patients are seen by a specialist dermatology nurse and a junior doctor. Each new patient is booked into a 90- Versiva® XC™ dressing minute assessment slot. Suitable patients has a semi-occlusive, are treated with ceftriaxone intravenous low moisture vapour therapy (IV), a once-a-day antibiotic IV transmission rate (MVTR) Versiva® XC™ dressing, incorporating backing preventing Hydrofiber® Technology, locks in1 fluid, ® treatment over a three-day period. After AQUACEL dressing helping protect periwound skin and receiving their first administration in clinic from drying out. reducing the risk of maceration2,3. they are discharged with a cannula in situ and receive their next two doses at home from the community IV team. On day four they return to the clinic for review where they are stepped down to oral antibiotics over a period of a further 11 days if their symptoms are improving.

The benefits of this are: 8 Ease of pressure on EAUM resources 8 Reduced waiting lists helping to achieve the four-hour target wait in A&E 8 Early discharge/prevention of admission 8 Patient is not exposed to hospital- AQUACEL® dressing, incorporating acquired infections Hydrofiber® Technology, creates a 8 Provision of a faster pathway moist wound environment to support healing and locks-in fluid1, helping 8 Care in the community. The patient protect the peri-wound skin and remains closer to home reducing the risk of maceration2,3. 8 Treatment of skin conditions prevents recurrent episodes of cellulitis.

Studies have supported this change of clinical pathway and management of lower limb cellulitis. Seton et al (2005) recognised high standards in nurse-led home IV services using IV ceftriaxone. They concluded that care is not compromised and the need for medical review is reduced. Caplan et al (1999) and Corwin et al (2005) state home IV treatment is as effective as hospital inpatient treatment as well as being more acceptable to patients. To date, this clinic has seen 500 cases of lower leg cellulitis. Out of this cohort only References 12 (10.6%) patients have been admitted 1. Walker M, Hobot JA, Newman GR, Bowler PG. Scanning electron microscopic examination of bacterial immobilisation in a carboxymethyl cellulose (Aquacel) and alginate dressings. Biomaterials. 2003;24(5):883-890. 2. Coutts P, Sibbald RG. The effect of a silver-containing Hydrofiber dressing on superficial wound bed and bacterial balance of Chronic Wounds. Int. Wound J. 2005;2:348-356. Wounds UK, 2008, Vol 4, No 4 3. Robinson BJ. The use of a hydrofibre dressing in wound management. J. Wound Care. 2000;9(1):32-34.35

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to hospital; 76.5% had confirmed cellulitis, British Lymphology Society, Lymphoedema Fleischer AB, Feldman SR, McConnell CF, 23.4% had differential diagnosis, 33.6% Support Network (2007) Concensus Document Petrazzuoli M, Pardasani AG, Hess MR (2002) had co-existing primary skin disease on Management of Cellulitis in Lymphoedema. Tinea pedis. In: Emergency Dermatology: A British Lymphology Society and the Rapid Treatment Guide. McGraw-Hill, New — either tinea pedis or venous eczema. Lymphoedema Support Network, London York: 392–5 This has produced a massive saving on bed Burzykowski T, Molenberghs G, Abeck D, Halpern J, Holder R, Langford NJ (2008) days offset against the cost of outpatient et al (2003) High prevalence of foot diseases Ethnicity and other risk factors for acute lower treatment. In recognition of this service in Europe: results of the Achilles Project. limb cellulitis: a UK-based prospective case- innovation, the clinic received the Health Mycoses 46(11–12): 496–505 control study. Br J Dermatol 158(6): 1288–92 Enterprise East Innovation Award in 2008. Caplan G, Ward J, Brennan N, et al (1999) Higgins EM, Fuller LC, Smith CH (2000) Hospital in the home: a randomised Guidelines for the management of Tinea Conclusions controlled trial. Med J Aust 170: 156–60 capitis. Br J Dermatol 143(1): 53–8 The recognition and treatment of Corwin P, Toop L, McGeoch G, et al (2005) Holden CA, Berth-Jones J (2004) Eczema, dermatological skin disease in patients Randomised controlled trial of intravenous lichenification, prurigo and erythroderma. In: presenting with cellulitis of the lower limb antibiotic treatment for cellulitis at home Burns T, Breathnach S, Cox N, Griffith C eds. is arguably a crucial part of this condition’s compared with hospital. 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