Cellulitis Recurrence Score: A tool for predicting recurrence of lower limb cellulitis

Development and validation of the Baseline Recurrence Risk in Cellulitis (BRRISC) score

OBJECTIVES

Cellulitis is often treated with antibiotics for longer than recommended by guidelines. Prolonged therapy may reduce recurrence in certain patients, but it is not known which patients are at greatest risk. Our objective was to develop and temporally validate a risk prediction score to identify patients attending hospital with cellulitis at highest risk of recurrence.

METHODS

We included UK adult patients with cellulitis attending hospital in an electronic health records (EHR) study to identify demographic, comorbid, physiological, and laboratory factors predicting recurrence (before death) within 90 days, using multivariable logistic regression with backwards elimination in complete cases. A points-based risk score integerised model coefficients for selected predictors. Performance was assessed using the C-index in development and temporal validation samples.

RESULTS

The final model included 4938 patients treated for median 8 days (IQR 6-11); 8.8% (n = 436) experienced hospitalisation-associated recurrence. A risk score using eight variables (age, heart rate, urea, platelets, albumin, previous cellulitis, venous insufficiency, and liver disease) ranged from 0-15, with C-index = 0.65 (95%CI: 0.63-0.68). Categorising as low (score 0-1), medium (2-5) and high (6-15) risk, recurrence increased fourfold; 3.2% (95%CI: 2.3-4.4%), 9.7% (8.7-10.8%), and 16.6% (13.3-20.4%). Performance was maintained in the validation sample (C-index = 0.63 (95%CI: 0.58-0.67)). Among patients at high risk, four distinct clinical phenotypes were identified using hierarchical clustering 1) young, acutely unwell with liver disease; 2) comorbid with previous cellulitis and venous insufficiency; 3) chronic renal disease with severe renal impairment; and 4) acute severe illness, with substantial inflammatory responses.

CONCLUSIONS

Risk of cellulitis recurrence varies markedly according to individual patient factors captured in the Baseline Recurrence Risk in Cellulitis (BRRISC) score. Further work is needed to optimise the score, considering baseline and treatment response variables not captured in EHR data, and establish the utility of risk-based approaches to guide optimal antibiotic duration.

Diagnostic methods for the confirmation of non-purulent cellulitis: a review

Cellulitis is the most common cause for skin disease hospitalization with costs totaling over $7 billion. It can be challenging to diagnose due to clinical similarities with other inflammatory conditions and the lack of a gold-standard diagnostic test. This article reviews the different testing methods for the diagnosis of non-purulent cellulitis based on three categories (1) clinical scoring assessments, (2) in vivo imaging techniques, and (3) laboratory assessments.

Prevention and treatment of recurrent cellulitis

PURPOSE OF REVIEW

Recurrent cellulitis is a challenging clinical condition affecting up to 47% of patients after the first episode, especially those with predisposing risk factors. The purpose of this review is to describe the state of the art of literature evidence and to highlight recent developments in its management.

RECENT FINDINGS

Recurrent cellulitis can occur after successful treatment of cellulitis. Conditions that commonly increase the risk of cellulitis include local and systemic modifiable and nonmodifiable factors. A rigorous approach to the management of risk factors and treatment of acute infection is important as the risk of recurrence rises with repeated episodes. Risk factors, if present, need to be targeted in association with antibiotic prophylaxis. Penicillin V is the preferred antibiotic for prevention but other antibiotics and new drugs can be considered in cases of β-lactam allergy, intolerance, or failure.

SUMMARY

Recurrent cellulitis is associated with short term and long-term morbidity as well as significant healthcare costs. Management of underlying predisposing conditions is crucial to prevent recurrence in addition with evaluation of pharmacological measures, but specialized and multidisciplinary skills are needed. More efforts are needed to prevent and treat this underestimated problem.

Prophylactic antimicrobials may not be needed to prevent surgical site infection after skin biopsy: a retrospective study

Background

Two types of skin biopsies are routinely performed in dermatology: excisional and punch biopsies. A punch biopsy is a relatively low-risk procedure for surgical site infections (SSIs) because of the shallow wound depth and short operative time. In Japan, prophylactic antimicrobial agents are often used after skin biopsies due to lack of consensus, and there is no mention of antimicrobial use after skin biopsies in Japanese guidelines. In this study, we investigated whether prophylactic antibiotic use after punch biopsies reduces the risk of SSI development.

Methods

Cases of punch biopsy performed in our dermatology department during a one-year period from April 2018 to March 2019 were included retrospectively. The cases were divided into a group with and another without prophylactic antimicrobial use after biopsy.

Results

A total of 75 cases of punch skin biopsy were reviewed. There were no cases of wound infection after punch biopsy in any of the groups. The number of years of experience of the physicians in the group that used antimicrobials was significantly higher than that in the group that did not use antimicrobials (P < 0.0001).

Conclusions

Our result suggests that the incidence of SSI in punch biopsies without prophylaxis seems to be low. However, further research is needed due to the small number of cases in this study.

Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis?

Recurrent cellulitis following successful treatment is common and prevention should be a major component in the management of cellulitis. Conditions that increase the risk of recurrence include chronic edema, venous disease, dermatomycosis and obesity. These risk factors should be actively managed as further episodes of cellulitis increases the risk of recurrence. The role of non-antibiotic measures is important and should be first-line in prevention. Antibiotic prophylaxis is effective, but its role is limited to non-purulent cellulitis where risk factors are appropriately managed.

Clinical and immunologic differences in cellulitis vs. pseudocellulitis

Introduction: The immunologic mechanisms between cellulitis and pseudocellulitis differ greatly, even though their clinical presentations may overlap.Areas covered: This article discusses cellulitis and common entities within the pseudocellulitis spectrum including acute lymphedema, superficial venous thrombosis, allergic contact dermatitis, lipodermatosclerosis, stasis dermatitis, erythema nodosum, cutaneous gout, and bursitis. The literature search was conducted from PubMed search engine between March and May 2021.Expert commentary: While immunologic differences in cellulitis and the various entities of pseudocellulitis are clear, there is a practice gap in applying these differences to the clinic and hospital setting. Further, existing studies are weakened by the lack of a gold-standard diagnosis in this disease category. Additional work is necessary in developing a gold-standard for the diagnosis and secondly, to project these immunologic differences as biomarkers to differentiate sterile inflammation from a potential life threatening bacterial or fungal infection.

Cellulitis: A Review of Pathogenesis, Diagnosis, and Management

Cellulitis is a common skin infection resulting in increasing hospitalizations and health care costs. There is no gold standard diagnostic test, making cellulitis a potentially challenging condition to distinguish from other mimickers. Physical examination typically demonstrates poorly demarcated unilateral erythema with warmth and tenderness. Thorough history and clinical examination can narrow the differential diagnosis of cellulitis and minimize unnecessary hospitalization. Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit.

Long-Term Benzathine Penicillin Prophylaxis Lasting for Years Effectively Prevents Recurrence of Dermato-Lymphangio-Adenitis (Cellulitis) in Limb Lymphedema

Background: The lymphedema-affected limbs are predisposed to acute and, subsequently, chronic dermato-lymphangio-adenitis (DLA) episodes in around 40%-50% of cases, irrespective of what the primary etiological factor is for the development of this condition. DLA is of bacterial etiology, and it needs antibiotic control and prevention of recurrence. Aim: To follow the effects of years-long continuous no-break administration of benzathine penicillin on the recurrence of acute DLA episodes. Methods and Results: Two hundred thirty-one patients were affected with lymphedema of lower and upper limbs. The mean duration of lymphedema was 10.2 ± 7.3 (range 2-30) years, and the number of DLA attacks/patient was 3.3 ± 3.2 (range 1-10). The total number of DLA episodes was 805. Benzathine penicillin injections 1,200,000 units were given i.m. at 14-21 days intervals (mean 18 ± 9 days) with short accidental breaks only. The period of therapy was 39.2 ± 38.7 (median 32) months. Recurrence occurred in 23 out of 231 (10%) (p < 0.01). There were 42 DLA incidents compared with 805 before introduction of therapy (5.2%) patients (hazard ratio 0.05, 95% confidence interval 0.034-0.079) (p < 0.01). Among patients with recurrence, there was a decrease of DLA episodes from 6.2% ± 3.6% to 1.7% ± 1.0%/patient. There were no differences in effectiveness of penicillin prophylaxis between etiological groups, depending on stages of lymphedema. Conclusions: Long-term years-long benzathine penicillin prophylaxis is extremely effective in prevention of DLA recurrence. It can be applied for years with no breaks, without clinical side-effects, and raising resistance to antibiotics. Microbial colonization and evoked inflammatory reaction of hosts should be controlled from the first symptoms of lymph stasis, irrespective of the etiology of lymphedema.

Predictors for readmission due to cellulitis among Japanese patients

Cellulitis is an infection of the soft tissues of the skin. Some patients are hospitalized multiple times; lymphedema, chronic venous insufficiency, peripheral circulatory disturbance, and deep vein thrombosis are said to be risk factors for multiple admissions. Conversely, in Japan, elderly women and undernourished elderly have been reported to be at risk of multiple hospitalizations, suggesting a different patient background from that reported overseas. We investigated the characteristics of readmission cases for patients hospitalized for cellulitis in Japan. We retrospectively examined cases of cellulitis and erysipelas admitted between April 1, 2005 and March 31, 2018. Patients with cellulitis or erysipelas at multiple sites and those with osteomyelitis, pressure ulcer infection, and necrotizing fasciitis were excluded. In terms of recurrence, only hospitalizations for recurrence at the same site were considered. Patients with multiple hospitalizations had significantly lower blood albumin levels than those hospitalized only once. Furthermore, the rates of lymphedema, hypertension, and hyperlipidemia were significantly higher in patients hospitalized multiple times. Other laboratory and clinical factors were not statistically significant. Therefore, hypoalbuminemia with or without liver dysfunction, lymphedema, hypertension, and hyperlipidemia were suggested as risk factors for cellulitis recurrence. However, chronic venous insufficiency, peripheral circulatory disturbance, and deep vein thrombosis did not seem to be risk factors in Japanese cases. Japanese cases had a low body mass index (approximately 25 kg/m²), suggesting that the patient background may be different from that in existing reports. This suggests that the risk factors in Japanese cases may be different from those reported in other countries.

Clinical features, microbiological epidemiology and recommendations for management of cellulitis in extremity lymphedema

BACKGROUND

This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema.

METHODS

From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inflammatory markers, cultures and antibiotic therapy regimens were compiled from cellulitis episodes data. Univariate and multivariate analyses were performed for detailed analysis.

RESULTS

A total of 131 separate episodes of cellulitis were recorded from 43 (81.1%) lower limb and 10 (19.9%) upper limb lymphedema patients. The prevalence and recurrence rates for cellulitis in lymphedema patients were 12.6% (53 of 420) and 56.6% (30 of 53), respectively. The most common findings were increased limb circumference (127 of 131; 96.9%) and abnormal C-reactive protein (CRP) level (86 of 113; 76.1%). Blood cultures were obtained in 79 (60.3%) incidents, with 9 (11.4%) returning positive. Streptococcus agalactiae was the most isolated bacterium (5 of 9; 55.5%).

CONCLUSIONS

The cellulitis prevalence and recurrence rate in extremity lymphedema were 12.6%, and 56.6%, respectively. Strongest indicators of cellulitis were increased affected limb circumference and elevated CRP level. Empiric antibiotic therapy began with coverage for Steptococcus species before broadening to anti-Methicillin-resistant Staphylococcus aureus and anti-Gram negatives if needed for effective treatment of extremity lymphedema cellulitis.

Comorbidities as Risk Factors for Acute and Recurrent Erysipelas

BACKGROUND:

Erysipelas is a common infectious skin disease. A typical feature of erysipelas, especially on the lower limbs, is the tendency to reoccur and the study aimed to define the comorbidities associated with it.

AIM:

We aimed to investigate systemic and local comorbidities in patients diagnosed with erysipelas on the lower limbs.

MATERIAL AND METHODS:

We conducted a retrospectively-prospective, population-based cohort study which included all patients diagnosed with erysipelas on the lower limbs, during two years. Patients were divided into two groups: patients with first episode and patients with recurrent erysipelas. These two groups were compared, with particular emphasis on systemic and local comorbidities.

RESULTS:

The study included 313 patients, of which 187 with the first episode of erysipelas and 126 with a recurrent. Regarding the analyzed systemic risk factors, the recurrent erysipelas was significantly associated with obesity (p < 0.0001), insulin dependent diabetes mellitus (p = 0.0015), history of malignant disease (p = 0.02) and tonsillectomy (p = 0.000001). For a p-value < 0.0001, significantly more frequent finding of peripheral arterial occlusive disease, chronic oedema/lymphoedema, fungal infections of the affected leg and chronic ulcer was confirmed in recurrent erysipelas. Neuropathy had 23% of the recurrent cases and 8.6% in patients without recurrence, and the difference was found to be significant for p = 0.0003. The only dissection of the lymph nodes was found more frequently in recurrent erysipelas (p = 0.017), but no associations with other analysed local surgery on the affected leg. Patients with recurrent erysipelas had ipsilateral coexisting dermatitis p = 0.00003 significantly more frequent. Minor trauma often preceded the first episode of erysipelas p = 0.005.

CONCLUSION:

Identification and treatment of modifiable risk factors are expected to reduce the risk of a subsequent episode of erysipelas on the lower limbs.

Epidemiology and risk factors for recurrent severe lower limb cellulitis: a longitudinal cohort study

OBJECTIVE

To describe the epidemiology and risk factors for recurrence of severe lower leg cellulitis (LLC).

METHODS

A longitudinal cohort study using state-wide data of adults presenting with recurrent LLC following a primary episode occurring between January 2002 and December 2013. The incidence of recurrent LLC was estimated using the cumulative incidence function, accounting for mortality. Independent risk factors for recurrence were identified using Fine-Gray sub-distribution and Cox proportional hazards models.

RESULTS

Of 36 276 patients presenting with their first episode of LLC, 4598 had at least one recurrence during the follow-up period. The cumulative incidence of first, second, and third recurrences at 12 months since previous infection was 6.3% (95% CI 6.0-6.5), 17.2% (95% CI 16.1-18.4), and 29.4% (95% CI 26.8-31.9), respectively, and at 5 years was 13.9% (95% CI 13.5-14.3), 35.9% (95% CI 34.2-37.5), and 52.9% (95% CI 49.5-56.2), respectively. The length of hospitalization increased from 3 days for the primary episode to 4 and 5 days for first and all subsequent recurrences, respectively. Independent risk factors for recurrent LLC included age, ethnicity (Indigenous Australian), local factors relating to lower leg pathology, conditions that commonly result in peripheral oedema, and systemic conditions that may be associated with increased leg size.

CONCLUSIONS

LLC recurrences are frequent, and each episode increases the likelihood of subsequent recurrence and length of hospitalization. These data provide context and scope to develop workable and effective strategies to prevent secondary episodes for all cases of primary LLC.

Reflection on the cause and avoidance of recurrent venous leg ulcers: An interpretive descriptive approach

AIMS AND OBJECTIVES

To gain insight into the experience of recurrent venous leg ulcers from the individual's perspective and provide knowledge on potential risks of recurrence not previously investigated.

BACKGROUND

Venous leg ulcers are a consequence of chronic venous disease and frequently recur. They are costly and can impact on physical and psychological health. Despite research suggesting the risk can be reduced through compression and lifestyle changes, recurrence rates are often high. This study provides an insight into individual's perceptions of the cause of their ulcers and how they try to avoid them.

DESIGN

A qualitative design guided by the Chronic Illness Trajectory Model and Social Cognitive Theory.

METHOD

A purposive sample of three males and four females were recruited from a community nursing clinic. Participants were ulcer free, had experienced at least two previous venous leg ulcers and could speak and comprehend English. An interpretive descriptive approach was taken using semi-structured interviews and thematic analysis.

RESULTS

Three themes each containing three categories emerged: The Increasing Influence of the Recurring Wound on Mind and Body, Reflection on Past Experiences and Optimism in the Face of Adversity. Most participants reported traumatic injury and lower leg surgery triggered ulcer recurrence. Failure to replace compression stockings was also deemed a cause. Compression was reported essential, but some participants were unaware of the level they were wearing and how often it should be replaced. Other preventive activities included avoiding injury and securing immediate assistance if wounding occurred.

CONCLUSION

Clinicians need to be aware that lower leg surgery may trigger recurrent venous ulceration and that individuals require ongoing emotional, physical and financial support throughout the trajectory of venous disease. The continued use of old compression stockings should be avoided and recurrence prevented by adoption of evidence-based practice rather than reflection on past experiences.

RELEVANCE TO CLINICAL PRACTICE

This research raises the awareness of factors from the individual's perspective which can influence the recurrence of venous leg ulcers.

Interventions for the prevention of recurrent erysipelas and cellulitis

BACKGROUND

Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear.

OBJECTIVES

To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16.

SEARCH METHODS

We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews.

SELECTION CRITERIA

Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis.

DATA COLLECTION AND ANALYSIS

Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality.

MAIN RESULTS

We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study.Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow-up period of up to one and a half to two years. Four studies were single-centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria.Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate.Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate-certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate-certainty evidence).The protective effects of antibiotic did not last after prophylaxis had been stopped ('post-prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty.Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years.We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay.The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin).None of the included studies assessed the development of antimicrobial resistance or quality-of-life measures.With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding.

AUTHORS' CONCLUSIONS

In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate-certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low-certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low-certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high-quality studies are warranted, including long-term follow-up and other prophylactic measures.

Comparisons Between Cancer-Related and Noncancer-Related Lymphedema: An Overview of New Patients Referred to a Specialized Hospital-Based Center in Canada

BACKGROUND

Lymphedema is an irreversible inflammatory condition caused by accumulated lymph fluid and is associated with chronic swelling and increased risk of cellulitis. Our objectives were to: (1) describe the patient population referred to a Canadian lymphedema center and (2) compare lymphedema characteristics between patients with cancer and patients with noncancer diagnoses.

METHODS AND RESULTS

A retrospective cohort study was conducted of new patients referred for suspected lymphedema to a hospital-based center over a 2-year period. The mean age of the patients (n = 429) was 61.4 years; 85% were female and 81% had a history of cancer. Lymphedema characteristics were primary (7%) versus secondary (92%); upper body (51%) versus lower body (45%); unilateral (74%) versus bilateral (25%); and history of cellulitis (22%). Patients with noncancer diagnoses (n = 82) were more likely than patients with cancer diagnoses (n = 347) to have a history of cellulitis (44% vs. 17%), to have bilateral (61% vs. 16%) and lower limb (89% vs. 37%) lymphedema, and to experience a long delay between symptom onset and referral (14.0 vs. 3.5 years) (p < 0.001).

CONCLUSION

Most patients referred to our lymphedema center were female with a history of cancer. However, patients with noncancer diagnoses were more likely to have bilateral lower body lymphedema with an important history of cellulitis; this subgroup is at great risk of missed and delayed diagnoses in the medical setting and of experiencing long-term issues with mobility, recurrent hospitalizations, and poor quality of life.

Recurrent SDSE bacteraemia resulting in streptococcal toxic shock syndrome in a patient with Noonan syndrome

A 19-year-old man with chronic lymphoedema due to Noonan syndrome presented at our hospital with septic shock and pain in his lower leg. Blood cultures were positive for Streptococcus dysgalactiae subsp equisimilis (SDSE), resulting in a diagnosis of cellulitis with toxic involvement. He was treated with ampicillin for 3 weeks. Although he did well for 6 weeks, septic shock recurred. Blood culture again revealed SDSE, with the strain being identical to the first episode, suggesting that this infection had relapsed. He was treated with ampicillin for 6 weeks and prophylactically with trimethoprim-sulfamethoxazole for 12 months. Although SDSE bacteraemia occurs commonly in elderly patients, findings in this patient showed that it can also develop in younger persons with predisposing factors. This case also indicates that SDSE has the potential to recur, despite generally sufficient antibiotic administration, and that patients who experience recurrent episodes may require prolonged treatment with antibiotics, including prophylaxis.

Inpatient Consultative Dermatology

Dermatology consultation can improve diagnostic accuracy in the hospitalized patient with cutaneous disease. Dermatology consultation can streamline and improve treatment plans, and potentially lead to cost savings. Dermatology consultants can be a valuable resource for education for trainees, patients, and families. Inpatient consultative dermatology spans a breadth of conditions, including inflammatory dermatoses,infectious processes, adverse medication reactions, and neoplastic disorders, many of which can be diagnosed based on dermatologic examination alone, but when necessary, bedside skin biopsies can contribute important diagnostic information.