When the skin is injured, bacteria can invade it and cause an abscess or phlegmon. In both types of infections, the skin becomes inflamed, red, and painful, often causing fever and general malaise.

Erysipelas, also called St. Anthony’s fire, usually affects only the upper layers of the skin, however a phlegmon usually extends deeper into the tissue. If treated early and properly, they usually heal without consequential damage. If left untreated, they can sometimes lead to serious complications.

Symptoms of erysipelas

Physical discomforts such as fever, accompanied by headaches, chills that run through the body, nausea or fatigue and a strong feeling of being ill, are usually one of the first symptoms of erysipelas, and are often confused with flu or cold states.

Faced with symptoms of this nature, it is necessary to consult a doctor as soon as possible, as they can be a sign of a serious illness.

There are two types of bacterial skin infections:

  1. Erastus;
  2. Deep inflammation of the connective tissue (phlegmon).

Both infections are most common in the foot or lower leg , but can occur in other parts of the body as well. For example, redness of the wound may develop on the face (“facial rose”), or on the flexor side of the hand. There it can extend in a V shape into the tendon sheaths between the thumb, wrist, and little finger.

Erysipelas affects the upper layers of the skin. This is usually expressed by a painful, bright red, and relatively acute inflammation.

The redness can form line-shaped marks as the inflammation spreads along the lymphatic vessels. In severe forms, bubbles are also formed.

Sometimes nearby lymph nodes become swollen and tender under pressure. This condition usually manifests at first with redness of the skin and heat in the area, and is accompanied by a general feeling of discomfort and illness.

In the presence of a phlegmon, the redness is less limited than in erysipelas and often appears dark red to light purple in contrast to the pink color of erysipelas.

Also, the inflammation in a phlegmon goes deep into the layers of the skin and into the underlying tissue. The inflammation can spread along the tendons or muscles and form pus.

Pain and swelling from inflamed skin and connective tissue are typical of both forms. Fever and malaise are more likely to occur with erysipelas, but can also occur with pronounced phlegmon.

What are its causes and risk factors

This condition is often caused by bacteria from the streptococcus group , while phlegmon is usually caused by staph. Both types of bacteria can be involved in both one disease and the other. [1,2]

Infections are favored by damage to the skin, which offers bacteria a so-called portal of entry. Therefore, risk factors include skin diseases such as atopic dermatitis , fungal infections such as athlete’s foot, or wounds and ulcers. In addition, it can also develop after injuries, cuts, insect or animal bites, or if germs have penetrated the wound in an operation.

Especially with a weakened immune system, the risk of infection increases. The immune system can be weakened, for example, with medications. These include certain anticancer drugs, cortisone, or drugs used after organ transplantation that suppress the body’s defense.

Also, people with diabetes, obesity, lymphatic or circulatory disorders, and venous insufficiency are at increased risk. Even erysipelas or a phlegmon is considered a risk factor.

It is recommended that skin diseases be treated quickly, so that the skin is well cared for, and regularly detects damage.

This is especially important in diabetes mellitus. Because this disease can reduce sensitivity to pain , with the result that small wounds, for example, on the feet are easily overlooked.

Diabetes mellitus is also a major risk factor for other skin and soft tissue infections, such as phlegmon caused by staph or other bacteria such as gram-negative intestinal bacteria.

Possible complications with erysipelas

If the therapy is applied too late or is inadequate, and if the disease is very serious, an injury can cause various complications to the general health of the patient. Particularly at risk are patients with comorbidities or immunodeficiency:

  1. The lymphatic system can become attached due to inflammation, so the lymph no longer drains properly. It accumulates (lymphatic congestion) and accumulates in the tissue (lymph swelling, lymphedema). As a result, tissues are less supplied with nutrients and immune cells, which increases the risk of erysipelas appearing again, because individual streptococci survive and proliferate well in protein-rich lymph.
  2. If the disease is severe or not properly treated, the lymphatic inflammation can sometimes be massive and sometimes interspersed with connective tissue. This process is no longer reversible and can lead to so-called elephantiasis, massively thickened legs.
  3. The infection is accompanied by bleeding and blistering elevation of the upper layer of the skin.
  4. Adjacent veins can become inflamed (phlebitis, thrombophlebitis).
  5. If bacteria enter the bloodstream, there is a risk of life-threatening blood poisoning. This complication is very rare in erysipelas.
  6. The kidney is also in danger from infection, due to immune malfunction: the body forms antibodies against the body’s own structures, as they have similarity to the characteristics of streptococci. For example, 10 to 20 days after strep throat or skin infections, a certain form of nephritis may occur. Because it often goes unnoticed, a urinalysis is recommended 10-20 days after the onset of strep infection.
  7. Rarely, a dangerous complication of facial erysipelas can occur, in certain circumstances, bacteria are transported to the brain and cause meningitis or venous occlusion (cerebral venous thrombosis, sinus venous thrombosis).


Erysipelas therapy usually consists of the administration of antibiotics , usually penicillin V or penicillin G. These active substances fight bacteria (also called streptococci A), which usually cause erysipelas.

If there is a suspicion of a mixed infection with other pathogens, such as Staphylococcus dorado, cephalosporins such as cefazolin are suitable.

Inpatient (inpatient) therapy is often advised because antibiotics must initially be administered intravenously.

Antibiotic treatment can last from 10 to 14 days, and the intake of analgesics and antipyretics usually accompany the treatment. If erysipelas therapy in the form of antibiotic treatment receives a good response from the patient, those affected can take the drug in the form of tablets.

Pain relievers like acetaminophen, tilidine, and tramadol help fight pain. In addition, affected areas of the skin can be treated with cooling and disinfection sachets (eg, hydroxyquinolone or chloramine solution).

In the vast majority of cases, circulatory disorders, as well as skin and nail fungi promote the development of roses on the skin. Therefore, it is another goal of therapy to treat these diseases as well as possible.

By Dr. Eric Jackson

Dr. Eric Jackson provides primary Internal Medicine care for men and women and treats patients with bone and mineral diseases, diabetes, heart conditions, and other chronic illnesses.He is a Washington University Bone Health Program physician and is a certified Bone Densitometrist. Dr. Avery is consistently recognized in "The Best Doctors in America" list.

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