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Clinical REVIEW

Cellulitis and lymphoedema: a vicious cycle

Firas Al-Niaimi, Neil Cox

Cellulitis is a relatively common of the and associated with high morbidity and a burden on healthcare resources. Lymphoedema — the accumulation of fluid in interstitial spaces — can occur as a consequence of cellulitis. Similarly, the presence of chronic lymphoedema can predispose to recurrent episodes of cellulitis. This article explores the relationship between lymphoedema and cellulitis, with emphasis on diagnosis, management and methods of prevention.

Symptoms of cellulitis vary depending tests have a relatively low diagnostic yield. Key words on the severity, which can range from Skin swabs for culture from intact skin mild to a more severe form with systemic are not helpful, but the yield of positive Cellulitis involvement in the form of tachycardia, results increases if a likely portal of Lymphoedema hypotension, and general malaise with a entry is present or if there is secondary Prophylactic therapy marked inflammatory response (Morton blistering (Dupuy et al, 1999; Tsao and PATCH and Swartz, 2004). A typical presentation Johnson, 1997). Swabs from erosions, is painful swelling with that is exudate and ulcerations, if present, may hot and tender to touch, often preceded be more helpful (Tsao and Johnson, by ‘flu-like’ symptoms. Potential long- 1997). However, such lesions may have term consequences of cellulitis include secondary staphylococcal colonisation ellulitis is defined as an acute lymphoedema and leg ulceration and may not identify the primary cause, of the skin and (Cox, 2002). and swabs from pre-existing ulcers may Csubcutaneous tissue which is reveal several different . commonly caused by Various risk factors have been shown pyogenes or to be associated with cellulitis, with The main reason for the low rate (Morton and Swartz, 2004). The lower lymphoedema showing the strongest of identification of streptococci in leg is the most affected site, accounting association (Dupuy et al, 1999). This cellulitis is that the infection is of the for 75–90% of all cases (Tsao and is particularly the case in recurrent , not of the skin surface, so it is Johnson, 1997). The true incidence of cellulitis. Streptococcal cellulitis associated difficult to identify. Another possible cellulitis is hard to estimate but a review with lymphoedema can be aggressive reason is that treatment has often of all hospital admissions in a UK district with severe symptoms and morbidity been initiated at an early stage and general hospital showed that about (Bonnetblanc and Bedane, 2003). may mask symptoms of , making 3% of all admissions were for cellulitis microbiological identification more (Morris, 2004), thereby constituting a Identifying cellulitis difficult. A review of 50 patients with huge financial burden on healthcare Cellulitis is often clinically apparent due cellulitis showed that only 26% had fever resources. The NHS Institute for to the presence of tender erythematous at the time of active cellulitis (Hook et Innovation and Improvement noted that swelling of the affected limb and al, 1986). A study performed by one of there were 45,522 inpatient admissions systemic symptoms of malaise (Morton the authors showed that 40% of patients for cellulitis in 2003–2004, costing the and Swartz, 2004). Fever and raised with cellulitis admitted to hospital were NHS £87m (Carter et al, 2007). inflammatory markers may also be apyrexial and systemically well (Cox et al, present. Blistering and ulceration occur in 1998). Hospital clinicians are aware that severe forms of cellulitis, often associated some patients are referred because they with marked oedema (Cox, 2002). are ‘not getting better’ despite antibiotic Firas Al-Niaimi is Specialist Registrar in , Salford Various laboratory investigations have treatment, but this will often refer to Royal Hospital, Manchester, UK and Neil Cox is Consultant been used for diagnosis of cellulitis by redness or swelling which can persist for Dermatologist, Cumberland Infirmary, Carlisle, UK microbiological culture, but overall these some time after antibiotic treatment.

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Blood cultures have been shown contribute to the reduction in morbidity in London involving 823 patients, 28% of to give a low yield for diagnosis in the as well as future recurrence (Collins et al, patients with lymphoedema had had an absence of bacteraemia. A retrospective 1989; Carter et al, 2007). episode of cellulitis within the previous 12 study among 757 patients with community- months (Moffatt et al, 2003). acquired cellulitis showed that only 2% of Risk factors for cellulitis patients had a significant patient-specific Local factors in the affected limb are Dupuy et al (1999) found that microbial strain isolated (Perl et al, 1999). strongly associated with a predisposition lymphoedema was present in 18% of A slightly higher rate of positive blood for cellulitis. General factors that might be their patients affected with cellulitis cultures in patients with leg lymphoedema regarded as risk factors include obesity, involving 167 patients with 294 controls. has been demonstrated (Baddour and smoking, alcohol misuse and A different study in which patients who Bisno, 1985). The authors believe that mellitus. The association with diabetes, had two or more episodes of leg cellulitis blood cultures have a marginal impact smoking and alcohol has not been proven were investigated with lymphoscintigraphy on clinical management in the absence in retrospective studies (Dupuy et al, 1999), (n=15) found significant lymphatic of systemic symptoms and raised but obesity has been shown to be linked abnormalities, suggesting a link with inflammatory markers, and therefore do with an increased risk (Scheinfeld, 2004). infective episodes (Soo et al, 2008). not appear to be cost-effective. This does Sixty percent of those patients also not however apply for necrotising fasciitis, Local factors causing defects in the skin had abnormal lymphoscintigrams in which is a more serious infection affecting barrier may increase the risk of developing the leg that had not been affected by the deeper tissue structures associated cellulitis by acting as a portal of entry for cellulitis, suggesting that pre-existing with high mortality and systemic sepsis. micro-organisms (Morton and Swartz, lymphatic abnormalities can precede the Although less common than cellulitis, 2004; Cox, 2002; Dupuy et al, 1999). Skin occurrence of clinical cellulitis. Stoberl necrotising fasciitis is often confused with trauma, lacerations, puncture wounds, leg et al (1987) found similar findings of cellulitis, particularly at its early phase of ulcers, , toe web maceration abnormal lymphatic ducts among patients presentation where blood cultures have a and tinea pedis fall into this group. In a with cellulitis of the leg, and Damstra higher diagnostic yield (Cox, 2002). study involving 647 patients, 77% had local et al (2008) showed that 79% of 33 barrier defects that may have acted as patients with impaired lymph drainage Antistreptolysin titre (ASOT) levels portals of entry, 50% of which were fungal in the affected limb also had evidence of may confirm a streptococcal aetiology (mostly of the toe web) (Morris, impaired drainage in the unaffected limb. in retrospect, as this blood test result 2004). Among the aforementioned factors, is often raised as early as 7–10 days leg ulcers form the strongest risk (Dupuy These studies support the increasingly following a streptococcal infection, et al, 1999). accepted concept that previously and takes several weeks to subside undetected lymphatic abnormalities may (Cox, 2002; Eriksson et al, 1996). This Previous episodes of cellulitis be present among patients with cellulitis. investigation is particularly useful in are associated with a higher risk for Early detection of lymphatic abnormalities patients who are less likely to have a non- recurrence, possibly due to local soft through lymphoscintigraphy — the gold streptococcal aetiology (e.g. patients with tissue and lymphatic damage (de Godoy standard method for detecting lymphatic excoriated eczema, , et al, 2000). This risk increases particularly abnormalities — and lymphoedema, or leg ulcers), as a negative test helps to if other factors are present (Bjoornsdottir and treatment of any abnormalities exclude a streptococcal cause. Conversely, et al, 2005). detected, may therefore reduce future confirming streptococcal infections can be episodes of cellulitis. However, there are useful when choosing antibiotic therapy A retrospective study among patients obvious practical limitations to this, as the for patients with recurrent cellulitis. with cellulitis who were followed for up abnormalities demonstrated are often to three years showed that 47% had a not easy to treat. Skin biopsy and/or aspirate have history of recurrent episodes (Cox, 2006). been shown to be of limited value in the Another study (n=233) showed that 29% Management of cellulitis diagnosis of cellulitis, but may have a role of patients had a recurrence within the The aim of treatment in cellulitis is in excluding some differential diagnoses first three years after their initial cellulitis resolution of the symptoms, reducing the such as or eosinophilic cellulitis (Jorup-Ronstrom, 1986). duration of hospital admission and the in those with atypical presentations (Tsao avoidance of sequelae such as oedema and Johnson, 1997; Morton and Swartz, Lymphoedema has been shown and ulceration. General measures such as 2004; Cox, 2002). in several studies to be the strongest bed rest, elevation of the affected leg, skin risk factor for cellulitis (Dupuy et al, and wound care and analgesia are the Treatment with antibiotics (oral 1999; Duvanel et al, 1989), particularly first-line treatments for cellulitis (Morton or intravenous) will be discussed later, in recurrent cellulitis. This is specifically and Swartz, 2004; Cox, 2002). Antibiotics however, elimination and treatment linked to leg oedema secondary to are required to eradicate the causative of potential risk factors such as lymphoedema and is much less the organism, however, national prescribing , tinea pedis or leg ulcers case with oedema secondary to venous advice on choice and duration of and the control of lymphoedema, all insufficiency. In an epidemiological study antibiotic therapy for cellulitis varies.

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Generally, oral antibiotics are used for the the bacteria). However, alone is Current guidance regarding milder forms of cellulitis where systemic not recommended as first-line therapy prophylaxis in cellulitis is suggested by the involvement is minimal. Currently, in the UK, due to its limited effect against BLS if two or more episodes of cellulitis recommendations for antibiotic choice staphylococci (CREST, 2005; CKS, 2006; occur annually. The recommendation vary with three different guidelines/ Mortimer et al, 2006). This is potentially for phenoxmethylpenicillin is partly due recommendations currently existing important as clinical diagnosis of the to its long-term safety profile — as in the UK (Clinical Resource Efficiency infective organism may be difficult, opposed to which carries Support Team [CREST], 2005; Clinical especially in early localised cellulitis or in the risk of hepatic toxicity if used long Knowledge Summaries [CKS], 2006; cellulitis with a wound as the portal of term (Mortimer et al, 2006) — and Mortimer et al, 2006). entry. Flucloxacillin as first-line treatment, also because recurrent cellulitis, with or as recommended by CREST and CKS, without a background of lymphoedema, is The CREST guidance (2005) suggests also has a low MIC for streptococci and most likely to be streptococcal infection. flucloxacillin as the first-line antibiotic in addition has anti-staphylococcal action. (intravenously in severe cases), with the Although the MIC of penicillin is more Lymphoedema macrolide clarithromycin for patients who favourable than that of flucloxacillin Oedema is defined as excessive are allergic to penicillin. In severe cases, for streptococci, flucoxacillin’s MIC is interstitial fluid which develops when intravenous can be used as sufficiently low that the addition of benzyl there is a discrepancy between the a substitute for clarithromycin in cases of penicillin to flucloxacillin in patients who microvascular filtration rate (in the penicillin allergy. do not respond to the latter is unlikely to capillaries and venules) and lymph produce added beneficial value. This has drainage. Increases in interstitial fluid CKS (2006) guidance recommends been proven by a study that showed no pressures and volume stimulate lymph flucloxacillin as first-line and difference in outcome when comparing flow through the collecting lymphatics. or clarithromycin in the case of penicillin a group of patients treated with This is the main process responsible for allergy. The suggested duration of flucloxacillin versus a group treated with interstitial fluid drainage. Impairment of treatment is for seven days for mild flucloxacillin and benzyl penicillin (Leman the lymphatic drainage in the face of infections and 10 days for more severe and Mukherjee, 2005). normal filtration will result in oedema forms. There is limited evidence available (lymphoedema). In healthy lymphatic for the estimated duration of treatment. Treatment of recurrent cellulitis ducts the lymph flow increases when One study with levofloxacin (which Despite the current limited evidence capillary filtration increases, thus is rarely used for cellulitis in the UK) regarding long-term treatment for preventing the formation of oedema showed that if response to treatment recurrent cellulitis, prophylactic therapy (Mortimer and Levick, 2004). occurs after five days, further treatment is widely used. Small studies suggest may not provide any additional benefit that oral antibiotic prophylaxis can be The process of lymph transport in the (Hepburn et al, 2004). beneficial and cost-effective (Jorup- leg is mainly an active process achieved Ronstrom, 1986; Pavlotsky et al, 2004), through contraction. This contractile Treatment of cellulitis in patients and a small study (36 patients in the mechanism of the smooth muscle walls of with lymphoedema differs slightly as the study randomised to two groups of 18 the collecting ducts is under the influence of causative organism is most likely to be patients each) showed that prophylactic the sympathetic system as well as the influx streptococcal. Based on this, the British erythromycin for 18 months resulted of calcium ions (Levick, 2004). Oedema Lymphology Society (BLS) recommends in no recurrences in cellulitis compared related to calcium channel blockers is, amoxicillin as first-line therapy for cellulitis with a placebo (Kremer et al, 1991). A therefore, likely to be partly through their with lymphoedema. Clindamycin is large multi-centre national study, being effect on lymphatics. Activation of the recommended as second-line for those coordinated by the UK Dermatology calf muscle pump through contraction allergic to penicillin (Mortimer et al, 2006). Clinical Trials Network, has already is generally believed to contribute to an enrolled five times as many patients as increase in lymph transport. The review of response after the largest of the above studies (170 to 48 hours is recommended in all the date), and will hopefully provide useful The term lymphoedema covers a guidelines (CREST, 2005; CKS, 2006; evidence about the role of penicillin range of pathologies, all of which present Mortimer et al, 2006). prophylaxis. Called PATCH (Prophylactic clinically as chronic swelling of one or Antibiotics for the Treatment of Cellulitis more limb(s) arising from a defect in In France, benzyl penicillin is the at Home), the study is a randomised the lymphatic channels. This implies a first-line recommended treatment for multi-centre clinical trial assessing fundamental failure in lymph transport, uncomplicated cellulitis (Societe Francaise whether prophylactic penicillin reduces as opposed to filtration oedema which de Dermatologie, 2001). Benzyl penicillin episodes of cellulitis in patients who had is caused by increased capillary filtration or phenoxymethylpenicillin both have recurrent (at least two episodes within (Mortimer and Levick, 2004). a low minimal inhibitory concentration the preceding 36 months) episodes of (MIC) against streptococci (i.e. low cellulitis (UK Dermatology Clinical Trials Primary lymphoedema is the term concentrations of the drug will inhibit Network’s PATCH Study Group, 2007). used for lymphoedema that arises from

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an abnormality of lymphatic development, combination with exercise in cases of that the relationship between cellulitis either due to genetic or congenital severe lymphoedema. and lymphoedema is a vicious cycle malformations in the collecting ducts (such where each episode of cellulitis further as Milroy disease and Klippel-Trenaunay Elevation of the affected leg may damages the lymphatic system, leading syndrome), or due to acquired abnormalities contribute by reducing the venous to a degree of secondary lymphoedema, such as lymphangio-obliterative pressure and subsequently the filtration. which in turn constitutes an increased lymphoedemas (Consensus Document of It is often used in conjunction with other risk for cellulitis (Collins et al, 1989; Woo the International Society of Lymphology measures, as leg elevation on its own has et al, 2000). In unpublished original data Executive Committee, 2003). This represents little effect on the lymphatic drainage. referred to in a Cochrane review, about a small percentage of lymphoedemas that a quarter of patients with lymphoedema often present after puberty. Manual lymphatic drainage (MLD) in will have at least one episode of cellulitis the form of massaging the affected limb or related in the affected Secondary lymphoedema refers may stimulate lymph drainage from the limb (Badger et al, 2004). to lymphoedema that is caused by root of the limb to the draining lymphatic an extrinsic process such as infection, basins. This is often combined with the This vicious cycle is independent from malignancy or surgery which damages aforementioned techniques. the primary aetiology of the lymphoedema a previously well-functioning lymphatic and is thought to be multifactorial. The system (Consensus Document of the Pneumatic compression therapy protein-rich lymphatic fluid serves as an International Society of Lymphology can be used to soften and reduce the excellent medium for bacteria to grow, and Executive Committee, 2003). limb volume but may displace fluid into stagnation of the lymphatic fluid due to adjacent areas and its use is therefore impaired lymph drainage with consequent Generally, if oedema is symmetrical a limited. The equipment used for this reduction in lymphatic clearance creates a systemic cause is likely to be found (e.g. method is designed to inflate and deflate state of local immune deficiency, which, in hypoalbuminaemia, nephrotic syndrome), around a swollen limb, exerting a pressure turn, can increase the risk of local cellulitis whereas unilateral limb oedema is often of 30–40mmHg. Although it increases the (Baddour and Bisno, 1985; Mortimer and the result of local pathology to the reabsorption of interstitial fluid, it has no Levick, 2004). lymphatic system. effect on the reabsorption of proteins. This leads to an increase in the concentration In patients without lymphoedema, Clinical lymphoedema manifests with of interstitial protein and results in bacterial components released from swelling, pitting and thickening of the skin, hardening of the treated limb (Mortimer bacteria are eliminated by phagocytosis which leads in time to a characteristic and Levick, 2004). Furthermore, single and/or antibiotics and are cleared efficiently papillomatous appearance and a warty chambered pumps have no direct effect by lymphatic drainage (Jeffs, 1998). (hyperkeratotic) texture. on lymph flow, and the high pressures can damage the superficial lymphatics. Baddour and Bisno (1985) postulated Treatment of lymphoedema that bacterial toxins which were ‘pooled’ The main component in the treatment It is well known that diuretics do in insufficiently drained lymphatic tissue of lymphoedema is an improvement in not play a role in the treatment of contribute to the systemic symptoms lymph drainage. This can be attempted lymphoedema and should only be used found in some patients with cellulitis, through several measures which will be in oedema secondary to salt and water complicating lymphoedema. This is largely explained briefly. retention (Mortimer and Levick, 2004). attributable to the release of cytokines as a host response to the presence of Exercise induces changes in interstitial The emergence of lymphoedema excessive lymph. It is unclear why there fluid pressure which leads to an increase clinics led by nurses, physiotherapists seems to be a great individual variance in in both the lymphatic filling and pressure, and doctors from various specialties the manifestation of systemic symptoms, with a consequential increase in the has allowed for an integrated service but it is likely that other host immune contractility of the lymphatic ducts. An that is aimed to offer patient-specific mechanisms play a role. increase in the flow of the non-contractile treatment(s) based on the degree of lymph ducts is likely to be influenced severity and any associated complications. Mortimer et al (2006) suggested by exercise which leads to the passive In severe forms of lymphoedema, a that once bacteria have gained entry to movement of lymph. combination of an intensive period of oedematous tissue, eradication proves treatment with multilayer bandaging, difficult and there is a risk of reactivation Compression through bandaging or exercise and MLD is used to reduce the of cellulitis if the local immune system is stockings aims to generate an increased swelling which is subsequently maintained impaired (Mortimer and Levick, 2004). interstitial pressure by opposing capillary with compression garments and exercise. The involvement of such mechanisms filtration, leading to an increased venous may provide an additional explanation return as well as to an increase in the Relationship between lymphoedema for the benefit of agents such as contractility of the lymphatic ducts. and cellulitis clindamycin and macrolides, as these have Multi-layer bandaging is often used in It is widely understood and accepted immunomodulatory actions as well as

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anti-streptococcal activity, and therefore Clinical Knowledge Summaries (2006) Kremer M, Zuckerman R, Avraham Z, Raz R may have a role in the treatment of Prodigy Guidance. Cellulitis. http://www.cks. (1991) Long-term antimicrobial therapy in the patients with recurrent cellulitis that library.nhs.uk/cellulitis. prevention of recurrent soft-tissue infections. J Infect 22(1): 37–40 complicates lymphoedema (Ritts, 1990). Clinical Resource Efficiency Support Team (2005) Guidelines on the Management of Leman P, Mukherjee D (2005) Flucloxacillin Cellulitis in Adults. Crest, Belfast. Available alone or combined with benzylpenicillin Conclusion online at: www.crestni.org.uk/publications/ to treat lower limb cellulitis: a randomised Cellulitis is a common and potentially cellulitis/cellulitis-guide.pdf controlled trial. 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