b'were rarely observed but included transient acuteA Cochrane review and subsequent partial update respiratory distress and transitory lobar atelectasis.concluded that it was not possible to define the best Although current literature suggests that pleurodesistreatment for cellulitis in general based on existing may be a viable second-line treatment for chylothorax,evidence 107,108 . Furthermore, the appropriate treatment the lack of controlled trials does not allow for aof cellulitis in lymphoedema may differ from cellulitis in definitive conclusion to be reached 102 . other clinical situations. C. TREATMENT OF CELLULITIS Prompt treatment is essential to reduce the risk of Author: Vaughan Keeley, MD worsening symptoms and the development of life-threatening conditions such as sepsis and to avoid Background further damage to the lymphatics of the affected part, The information shared in this section was approvedwhich in turn may predispose to repeated attacks. and provided by the British Lymphology Society andDecision to Manage Cellulitis at Hometaken directly from the most up-to-date Guidelines onVersus the Hospitalthe Management of Cellulitis in Lymphoedema last published in October 2022 by the British LymphologyA decision on whether hospital admissionSociety (BLS) and the Lymphoedema Support Networkis indicated should be based on the levelin the United Kingdom 103 .of system upset (i.e., signs of sepsis andhttps://www.thebls.com/documents-library/guidelines- continuing deterioration despite treatment).on-the-management-of-cellulitis-in-lymphoedema Absolute indications for hospitalization to manage What is Cellulitis? cellulitis include the following:Cellulitis is an acute spreading inflammation of the 1. SepsisSigns of sepsis including hypotension, skin and subcutaneous tissues characterized by pain, warmth, swelling, and erythema. Cellulitis is sometimestachycardia, severe pyrexia, delirium, tachypnea, or called erysipelas or lymphangitis. It is a commonvomiting).2. Continuing or deteriorating systemic signs, withcomplication of lymphedema, with one study of its prevalence in those attending a specialist lymphedemaor without deteriorating local signs, after 48 hours center reporting that 37.6% had experienced at leastof antibiotics.one episode and 23.3% had recurrent cellulitis 104 .3. Unresolving or deteriorating local signs, with However, in lymphedema, attacks are variable inor without systemic signs, despite trials with first- presentation and may differ from cellulitis occurring and second-line antibiotics. in other clinical situations. Most episodes are believed Management of Cellulitis at Hometo be caused by group A streptococci 105 . However,It is essential as the provider to monitor the patients microbiologists consider Staphylococcus aureus to response to initial treatment. Your patient shouldbe the cause in some patients, for example, Chiraand Miller 2010 106 . be educated and advised to seek further medical attention immediately should symptoms worsen orSome episodes are accompanied by severe systemicare not responding to a 48-hour course of antibiotics upset, with high fever, rigors and even sepsis; othersand treatment. are milder, with minimal or no fever. Increased swellingTo establish a baseline and to monitor the progress of of the affected area may occur. Inflammatory markersthe management of cellulitis, the following should be (CRP, ESR) may be raised. Cellulitis can be difficult considered:to diagnose and to distinguish from other causes of inflammation, particularly in the legs, e.g. lipodermato- 1. Extent and severity of rash/erythemaif possible,sclerosis (British Lymphology Society Red Legsmark and date the edge of the erythema (may be Pathway: https://www.thebls.com/public/uploads/ difficult in lymphedema as the rash is often blotchy) documents/document-40881639738634.pdf) 2. Level of systemic upset (record any systemCellulitis most commonly affects one leg only, symptoms)whereas lipodermatosclerosis more commonly 3. Laboratory markersmeasure C-reactive proteinaffects both legs.(CRP)/Erythrocyte Sedimentation Rate (ESR) and Although cellulitis in lymphoedema is most common incomplete blood cell count (CBC) with differentialthe limbs, it can occur in other areas of lymphoedema,as these may be helpful in diagnosis and monitoring e.g. genital. Treatment may need to be differentof treatment.depending on the site of lymphoedema. This is4. Always consider sending microbiology swabs of anyaddressed in these guidelines. cuts or breaks in the skin. This should be completed prior to the initiation of antibiotics. | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|27'