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Erysipelas: symptoms, forms, treatment. Erysipelas Signs of erysipelas

Erysipelas– an acute anthroponotic infectious disease caused by hemolytic streptococci, characterized by fever, intoxication, the presence of a local focus of serous-hemorrhagic skin lesions with a tendency to recur.

Etiology: group A b-hemolytic streptococcus.

Epidemiology: with an exogenous variant of infection, the source is patients with any streptococcal disease (angina, pharyngitis, scarlet fever, streptoderma, etc.) or healthy carriers of streptococcus, transmission routes are airborne, contact; with autoinfection, the pathogen enters the lesion from endogenous foci of streptococcal infection.

Pathogenesis: penetration of MB into the lesion by contact(through microtrauma of the skin) or hematogenously-lymphogenously (with autoinfection) -> activation of mediators of the allergic inflammatory reaction (in the presence of sensitization of certain areas of the skin to streptococcal Ag) -> development of serous or serous-hemorrhagic inflammation with hyperemia, edema and infiltration of the affected areas of the skin and subcutaneous tissue –> involvement of blood vessels in the process microvasculature, lymphatic capillaries, damage vascular walls–> elimination of streptococcus due to activation of phagocytosis and the humoral immune system while maintaining skin sensitization –> re-entry of streptococcus –> sclerosis and desolation of repeatedly damaged vessels, chronic lymphostasis up to elephantiasis; in addition to local ones, characteristic and general manifestations diseases caused by MB enzymes.

Erysipelas clinic:

– incubation period from several hours to 5 days

– acute onset of the disease with dominance of symptoms of general intoxication (remitting fever up to 39-40 °C, chills, general weakness, headache, pain in the lower back, muscles and joints, often nausea and vomiting, in some - convulsions, meningism), especially pronounced in the first days of the disease

– 12-24 hours after the disease occurs Local manifestations: pain, hyperemia and swelling of the affected skin area; the local process is more often located on the lower extremities, less often on the face and upper limbs, depending on its nature, they distinguish Clinical forms of erysipelas:

A) erythematous– the affected area of the skin is characterized by erythema of uniformly bright color rising above the skin, with clear boundaries, a tendency to peripheral distribution, irregularly shaped edges (in the form of jagged edges, “tongues of flame”), swelling and pain; subsequently, peeling of the skin may appear at the site of erythema

B) Erythematous-bullous– begins as erythematous, but after 1-3 days from the moment of illness, epidermal detachment occurs at the site of erythema and blisters of various sizes are formed filled with serous contents; subsequently the bubbles burst, and in their place form brown crusts, after rejection of which young, delicate skin is visible; V in some cases in place of the blisters, erosions appear that can transform into trophic ulcers.

V) Erythematous-hemorrhagic– occurs with the same symptoms as erythematous, however, against the background of erythema, hemorrhages appear in the affected areas of the skin.

D) bullous-hemorrhagic– has almost the same manifestations as the erythematous-bullous form of the disease, but the blisters that form at the site of erythema are filled not with serous, but with hemorrhagic exudate

Inflammatory skin changes in the erythematous form of erysipelas persist for 5-8 days, and in other forms - 10-15 days or more.

– characterized by moderate enlargement and sharp pain regionally in relation to the affected area of the skin. u. ( regional lymphadenitis), hyperemia, induration and soreness lymphatic vessels between the source of inflammation and the affected areas. u. (regional lymphangitis)

Complications of erysipelas (in 5-10% of patients with severe forms of the disease): phlegmon, abscesses (phlegmonous and abscess erysipelas), tissue necrosis of the affected area (gangrenous erysipelas), thrombophlebitis, chronic disorder lymph flow and lymphostasis (with development during repeated cases of elephantiasis), infectious toxic encephalopathy and infectious toxic shock, secondary pneumonia, sepsis

Diagnosis of erysipelas:

1) clinical and anamnestic data (acute onset of the disease, characteristic appearance lesion, history of erysipelas, identification of predisposing factors)

2) changes in the CBC: leukocytosis, neutrophilia with band shift, increased ESR

Differential diagnosis erysipelas is carried out with:

1) with phlegmon, abscess– with phlegmon, the lesion is not clearly demarcated from healthy tissue, the greatest pain is in the center of the lesion, intoxication appears later than local changes, with an abscess fluctuation is determined

2) with thrombophlebitis– soreness and hyperemia of the skin spread along the vascular bundle, dense painful cords are often palpated along the veins

3) with erythema nodosum – characterized by delimited multiple low-painful elements located symmetrically on the extensor surface of the legs, thighs, forearms, no lymphadenitis

4) with dermatitis, eczema– intoxication and fever are not typical, there is itching, weeping, infiltration and peeling of the skin

5) with ring-shaped erythema in Lyme disease– localized more often on the legs, has a ring-shaped shape with a pale center, in which you can see a mark from the tick’s suction; rapid onset and sudden intoxication are not typical

6) with erysipeloid– bacterial zoonosis caused by Erysipelothrix rhusiopathiae, which enters the body through damaged skin (usually the hands); The professional nature of the disease is typical (butchers, fish sellers, cooks), the appearance of swelling and erythema in the area of the hands, accompanied by burning and itching without fever and symptoms of general intoxication

Treatment of erysipelas:

1. Patients with a severe course of the disease, repeatedly recurrent erysipelas, in the presence of a severe premorbid background (diabetes, obesity, CHF) are subject to hospitalization; the rest are treated on an outpatient basis

2. Bed rest in the first 5 days, and in case of damage to the lower extremities, during the entire period of the disease.

3. Etiotropic therapy - drugs of choice: phenoxymethylpenicillin orally 0.5 g 4 times a day for 10-14 days, benzathine penicillin 2.4 million units intramuscularly once, alternative drugs - for allergies to beta-lactams: orally azithromycin 250 mg 1 once a day for 10-14 days, clarithromycin 250 mg 2 times a day for 10-14 days, clindamycin 300 mg 3 times a day for 10-14 days. At the end of the course of treatment, in order to prevent relapses, 1.5 million units of bicillin-5 or 1.2 million units of bicillin-3 are administered intramuscularly.

4. Vitamin therapy: multivitamins 2 tablets 3 times a day orally

5. After normalization of the temperature - FTL (suberythemal doses of ultraviolet irradiation to the affected area, UHF to the area of infiltration and regional l.u.)

6. For prolonged and recurrent erysipelas, hospitalization is indicated, followed by 2 courses of ABT with drugs of different pharmacological groups, immunomodulatory therapy (pentoxyl, methyluracil, prodigiosan), the use of corticosteroids (prednisolone 30-40 mg/day for 5-10 days), etc. .

7. In case of persistent relapses of erysipelas, bicillin prophylaxis is indicated: 1.5 million units of bicillin-5 IM 1 time per month for 3-5 years.

Erysipelas (or simply erysipelas) is one of the bacterial infections skin, which can affect any part of it and leads to the development of severe intoxication. The disease progresses in stages, which is why light form, which does not affect the quality of life, can become severe. Prolonged erysipelas without proper treatment will ultimately lead to the death of the affected skin and suffering of the entire body.

It is important that if there are characteristic symptoms of erysipelas, the patient consults a doctor, and does not treat himself, waiting for the disease to progress and complications to develop.

Causes of erysipelas

For erysipelas to occur, three conditions must be met:

Presence of a wound – there does not need to be extensive soft tissue damage for bacteria to penetrate the skin. A scratch, “cracking” of the skin of the legs or a small cut is enough;
If a certain microbe gets into the wound, it is believed that erysipelas can only be caused by hemolytic streptococcus A. In addition to local damage to the skin, it produces strong toxins and disrupts the functioning of the immune system. This is manifested by intoxication of the body and the possibility of erysipelas recurrent (appearing again after a certain time);
Weakened immunity - this factor has great value for the development of skin infection. Erysipelas practically does not occur in healthy people whose immunity is not weakened by another disease or harmful conditions life (stress, physical/mental overload, smoking, drug addiction, alcohol, etc.).

Despite the fact that the disease can occur in any person, under the above conditions, people mainly suffer old age. Also at risk are infants with diabetes, HIV, any cancer pathology, or taking glucocorticosteroids/cytostatics.

What is erysipelas?

There are several forms of erysipelas, which differ in the severity of symptoms, severity and treatment tactics. It should be noted that they can sequentially transform into one another, so it is important to start treatment in a timely manner.

In principle, the following forms of the disease should be distinguished:

Erythematous erysipelas - manifests itself with classic symptoms, without any additional skin changes;
Bullous form - characterized by the formation of blisters on the skin with serous contents;
Hemorrhagic (bullous-hemorrhagic) - the peculiarity of this type of erysipelas is that the infection damages small blood vessels. Because of this, blood sweats through their wall and forms blisters with hemorrhagic contents;
Necrotic is the most severe form, in which necrosis of the affected skin occurs.

Depending on the location, the erysipelas can be on the face, leg, or arm. Much less often, the infection forms in the perineum or other parts of the body.

Beginning of erysipelas

From the moment the wound becomes infected until the first symptoms appear, on average, 3-5 days pass. Symptoms of erysipelas of the skin of the face, arms, legs and any other localization begin with a rise in temperature and soreness of the affected area. As a rule, on the first day of illness there is a fever of no more than 38 o C. Subsequently, the body temperature can rise to 40 o C. Due to the action of streptococcus, the patient has all the characteristic signs of intoxication of the body:

Marked weakness;
Decreased/loss of appetite;
Increased sweating;
Increased sensitivity to bright light and irritating noise.

A few hours after the temperature rises (up to 12 hours), symptoms of damage to the skin and lymphatic structures appear. They differ somewhat, depending on the location, but they have one thing in common - pronounced redness of the skin. The erysipelas may spread beyond the affected area, or remain in only one area. This depends on the aggressiveness of the microbe, the body’s resistance to infection and the time of initiation of therapy.

Local symptoms of erysipelas

Common signs of erysipelas on the skin are:

Severe redness of the affected area (erythema), which rises slightly above the surface of the skin. The erythema is delimited from healthy tissues by a dense ridge, but with widespread erysipelas it may not be present;
Pain when palpating the area of redness;
Swelling of the affected area (feet, legs, face, forearms, etc.);
Soreness lymph nodes, near the source of infection (lymphadenitis);
In the bullous form, transparent blisters may appear on the skin filled with blood or serous fluid (plasma).

Besides common features, erysipelas has its own characteristics when localized in different parts of the body. They must be taken into account in order to suspect an infection in time and begin treatment in a timely manner.

Features of erysipelas of the facial skin

The face is the most unfavorable location for infection. This area of the body is very well supplied with blood, which contributes to the development of severe edema. Lymphatic and blood vessels connect superficial and deep structures, which is why there is a possibility of developing purulent meningitis. The skin of the face is quite delicate, so it is damaged by infection somewhat more severely than in other localizations.

Taking these factors into account, it is possible to determine the characteristics of the symptoms of erysipelas on the face:

The soreness of the infected area increases with chewing (if the erysipelas is located in the area lower jaw or on the surface of the cheeks);
Severe swelling not only of the reddened area, but also of the surrounding facial tissues;
Pain when palpating the sides of the neck and under the chin is a sign of inflammation of the lymph nodes;

Symptoms of intoxication when the skin of the face is infected are more pronounced than in other localizations. On the first day, body temperature may rise to 39-40 o C, severe weakness, nausea, severe headache and sweating may appear. Erysipelas on the face is a reason to immediately consult a doctor or the emergency room of a surgical hospital.

Features of erysipelas on the leg

There is a belief among doctors that erysipelas of the lower limb is closely related to violation of personal hygiene rules. Lack of regular foot washing creates excellent conditions for the proliferation of streptococci. In this case, one microtrauma (crack in the feet, small scratch or puncture) is enough for them to penetrate the skin.

Peculiarities clinical picture The erysipelas in the leg area are as follows:

The infection is located on the foot or lower leg. The hip is affected quite rarely;
As a rule, painful formations can be found in the area of the inguinal folds (on the front surface of the body where the thigh meets the torso) round shape- these are inflamed inguinal lymph nodes that inhibit the spread of streptococcal infection;
With severe lymphostasis, swelling of the leg can be quite severe and spread to the foot, ankle joint and lower leg. It is quite easy to detect - to do this, you need to press the skin against the bones of the lower leg with your finger. If there is swelling, then after the finger is removed the dimple will remain for 5-10 seconds.

In most cases, erysipelas of the lower extremities is much easier than with other infection locations. The exceptions are necrotic and complicated forms.

Features of erysipelas on the hand

Streptococcal infection affects the skin of the hands quite rarely, since it is quite difficult to create a large concentration of microbes around the wound. Erysipelas on the upper limb may be the result of a puncture or cut by a contaminated object. The risk group consists of preschool and school age, intravenous drug addicts.

Erysipelas on the hand is most often common - it affects several segments (hand and forearm, shoulder and forearm, etc.). Since the lymphatic pathways are well developed on the upper limb, especially in the axillary fossa, swelling can spread from the fingers to the pectoral muscles.

If you feel inner surface Regional lymphadenitis can be detected in the shoulder or armpits. Lymph nodes will be enlarged, smooth, and painful.

Diagnostics

The doctor can determine the presence of erysipelas after initial examination and palpating the affected area. If the patient does not have concomitant diseases, from additional methods For diagnosis, it is sufficient to use only a general blood test. The presence of infection will be indicated by the following indicators:

Erythrocyte sedimentation rate (ESR) is more than 20 mm/hour. During the height of the disease, it can accelerate to 30-40 mm/hour. Normalizes by the 2-3rd week of treatment (normal – up to 15 mm/hour);
Leukocytes (WBC) – more than 10.1*10 9 /l. An unfavorable sign is considered to be a decrease in the level of leukocytes less than 4*10 9 /l. This indicates the body's inability to adequately resist infection. Observed when various immunodeficiencies(HIV, AIDS, blood cancer, consequences radiation therapy) and with generalized infection (sepsis);
Red blood cells (RBC) - a decrease in level below normal (less than 3.8 * 10 12 / l in women and 4.4 * 10 12 / l in men) can be observed with hemorrhagic erysipelas. In other forms, as a rule, it remains within normal limits;
Hemoglobin (HGB) – can also decrease in the hemorrhagic form of the disease. The norm is from 120 g/l to 180 g/l. A decrease in the level below normal is a reason to start taking iron supplements (if prescribed by a doctor). A decrease in hemoglobin level below 75 g/l is an indication for whole blood or red blood cell transfusion.

Instrumental diagnostics are used in cases of impaired blood flow to the limb (ischemia) or the presence of concomitant diseases, such as obliterating atherosclerosis, thrombophlebitis, thromboangiitis, etc. In this case, the patient may be prescribed Doppler ultrasound of the lower extremities, rheovasography or angiography. These methods will determine vascular patency and the cause of ischemia.

Complications of erysipelas

Any erysipelas infection, if treatment is not started in a timely manner or the patient’s body is significantly weakened, can lead to the following complications:

An abscess is purulent cavity, which is limited by a capsule of connective tissue. It is the least dangerous complication;
Cellulitis is a diffuse purulent focus in soft tissues (subcutaneous tissue or muscles). Leads to damage to surrounding structures and a significant increase in symptoms of intoxication;
Purulent phlebitis is inflammation of the vein wall on the affected limb, which leads to its hardening and narrowing. Phlebitis is manifested by swelling of the surrounding tissues, redness of the skin over the vein and an increase in local temperature;
Necrotizing erysipelas - necrosis of the skin in the area affected by streptococcus;
Purulent meningitis - can occur when erysipelas is located on the face. This serious illness, which develops due to inflammation of the membranes of the brain. It manifests itself as general cerebral symptoms (unbearable headache, clouding of consciousness, dizziness, etc.) and involuntary tension of certain muscle groups;
Sepsis is the most dangerous complication erysipelas, which in 40% of cases ends in the death of the patient. This is a generalized infection that affects organs and leads to the formation of purulent foci throughout the body.

You can prevent the formation of complications if you seek medical help in a timely manner and do not treat yourself. Only a doctor can determine the optimal tactics and prescribe therapy for erysipelas.

Treatment of erysipelas

Uncomplicated forms of erysipelas do not require surgery - they are treated conservatively. Depending on the patient’s condition, the need for hospitalization is decided. There are clear recommendations only regarding erysipelas on the face - such patients should be treated only in a hospital.

The classic treatment regimen includes:

Antibiotic – optimal effect has a combination of protected penicillins (Amoxiclav) and sulfonamides (Sulfalene, Sulfadiazine, Sulfanilamide). As alternative drug Ceftriaxone can be used. Recommended period antibacterial treatment 10-14 days;
Antihistamine - since streptococcus can compromise the body's immunity and cause allergic-like reactions, this group of drugs should be used. Currently, the best (but expensive) drugs are Loratadine and Desloratadine. If the patient does not have the opportunity to purchase them, the doctor may recommend Suprastin, Diphenhydramine, Clemastine, etc. as an alternative;
Pain reliever – for erysipelas, non-hormonal anti-inflammatory drugs (NSAIDs) are used. Preference should be given to Nimesulide (Nise) or Meloxicam, as they have the least amount adverse reactions. An alternative is Ketorol, Ibuprofen, Diclofenac. Their use should be combined with taking Omeprazole (or Rabeprazole, Lansoprazole, etc.), which will help reduce negative impact NSAIDs on the gastric mucosa;
Antiseptic dressings with 0.005% Chlorhexidine are an important component of therapy. When applied, the dressing should be generously moistened with the solution and remain wet for several hours. A sterile bandage is applied over the bandage.

How to treat erysipelas of the skin if local complications arise or bullous erysipelas develops? In this case, there is only one way out - hospitalization in a surgical hospital and performing an operation.

Surgical treatment

As already mentioned, indications for surgery are the formation of ulcers (cellulitis, abscesses), skin necrosis or the bullous form of erysipelas. There's no need to be afraid surgical treatment, in most cases it takes no more than 30-40 minutes and is carried out under general anesthesia(under anesthesia).

During the operation, the surgeon opens the cavity of the abscess and removes its contents. The wound, as a rule, is not sutured - it is left open and a rubber outlet is installed to drain the fluid. If dead tissue is detected, they are completely removed, after which conservative therapy is continued.

Surgical treatment of the bullous form of erysipelas occurs as follows: the doctor opens the existing blisters, treats their surfaces with an antiseptic and applies bandages with a 0.005% solution of Chlorhexidine. This prevents the addition of foreign infections.

Skin after erysipelas

On average, treatment for erysipelas takes 2-3 weeks. As the local inflammatory response decreases and the amount of streptococcus decreases, the skin begins to renew itself. The redness decreases and a kind of film appears in place of the damaged area - this is the “old” skin being separated. As soon as it is completely rejected, it should be removed independently. There should be unchanged epithelium underneath.

For next week, peeling of the skin may persist, which is a normal reaction of the body.

In some patients, erysipelas can take a recurrent course, that is, appear again in the same place after a certain time (several years or months). In this case, the skin will be susceptible to trophic disorders, chronic swelling of the limb or replacement of the epithelium may form connective tissue(fibrosis).

Frequently asked questions from patients

Question:
How dangerous is this infection?

Erysipelas is a serious disease that is dangerous due to severe intoxication and the development of complications. As a rule, with timely treatment, the prognosis is favorable. If the patient comes a week or more after the onset of infection, his body is weakened by concomitant diseases (diabetes, heart failure, HIV, etc.), erysipelas can lead to fatal consequences.

Question:
How to restore skin after erysipelas?

In almost all forms of erysipelas, this process occurs independently, without the intervention of doctors. The main thing is to eliminate the source of infection and local inflammatory phenomena. The exception is necrotic erysipelas. In this case, the skin can only be restored surgery(skin plastic).

Question:
Why does erysipelas occur several times in the same place? How to prevent this?

In this case, we're talking about about a recurrent form of erysipelas. Group A streptococcus has the ability to disrupt the immune system, which leads to repeated inflammatory reactions in the affected skin. Unfortunately, adequate methods for preventing relapse have not been developed.

Question:
Why is the article not mentioning Tetracycline (Unidox, Doxycycline) for the treatment of erysipelas?

Currently, tetracycline antibiotics don't use for the treatment of erysipelas. Studies have shown that most hemolytic streptococci are resistant to this drug, so it is recommended to use the following antibiotics for erysipelas - a combination of synthetic penicillin + sulfonamide or 3rd generation cephalosporin (Ceftriaxone).

Question:
Should physical therapy be used to treat erysipelas?

No. Physiotherapy during the acute period will lead to increased inflammation and the spread of infection. It should be postponed until the recovery period. After suppressing the infection, it is possible to use magnetic therapy or ultraviolet radiation.

Question:
Does the treatment of erysipelas differ depending on the location of the infection (on the face, on the arm, etc.)?

Treatment of erysipelas of the arm, leg and any other part of the body is carried out according to the same principles.

Erysipelas or erysipelas is one of the variants of streptococcal lesions of the skin and underlying tissues, accompanied by general inflammatory reactions of the body. This disease is of infectious origin, but its contagiousness is not high. Mostly manifestations occur in the spring and summer.

Reasons

The disease is based on damage special kind streptococcus, beta-hemolytic, which, along with erysipelas, causes scarlet fever, streptoderma and tonsillitis.

With a sharp weakening of immunity during the disease, other microbes can become mixed in, causing purulent complications and difficulties in treatment.

For the development of erysipelas important role play:

violation of skin integrity, degenerative processes in the skin,
fungal skin infection,
presence of diabetes mellitus, capillary lesions, venous insufficiency,
occupational skin injuries, constant wearing of non-breathable clothing and shoes,
exposure of the skin to dust, soot, occupational hazards,
hypovitaminosis, decreased immunity, chronic diseases.

The pathogen enters the skin from carriers or patients with streptococcal infections. For its penetration, special conditions are required - abrasions, abrasions, skin defects. It develops more often in people with problems with immunity and local skin protection - in pregnant women, weakened people, the elderly, people with diabetes and chronic skin diseases.

Species

There are three forms of erysipelas:

erythematous with redness and swelling of the skin,
hemorrhagic, with bruises and hemorrhages of the skin,
bullous, with the formation of blisters in areas of redness.

Photo: website of the Department of Dermatovenereology of the Tomsk Military Medical Institute

Symptoms of erysipelas

The incubation period is about a day, the disease begins abruptly,

from an increase in temperature to 39-40 degrees,
general malaise with headache and muscle pain,
weakness with nausea, vomiting, high fever.

The lymph nodes are sharply enlarged, especially those closest to the area affected by streptococcus.

In the area of the skin that is affected by erysipelas, itching and burning of the skin initially occurs; as the disease progresses over the course of a day, all signs of inflammation develop - redness, heat and pain, the lesion sharply spreads and increases in size.

In the classic course of the disease, the skin has a bright red color, clear boundaries with intact tissue, the edges of the lesion are uneven, resembling flames, and the area of inflammation rises above the level of healthy skin.

The skin is hot to the touch; when palpated, it can be extremely painful; blisters filled with clear, sanguineous or purulent contents may form on the skin of the inflamed area. In the area of inflammation there may be minor hemorrhages in the form of bruises.

The main localizations of erysipelas are the nose and cheeks of the “butterfly” type, the area of the external ear canal and corners of the mouth. This localization is usually characterized severe swelling and pain. There may be lesions in the scalp area, on the lower extremities; less often, inflammation occurs in other areas.

With erysipelas, even with adequate treatment, there may be a fever for up to 10 days, and skin manifestations last up to two weeks.

After recovery, relapses of the disease can occur for up to two years, but with relapses, fever usually no longer occurs, and the diagnosis is made when red spots appear on the skin with slight tissue swelling.

Diagnostics

The basis of diagnosis is the manifestation of a characteristic set clinical symptoms erysipelas:

fever, toxicosis with sudden onset of illness,
defeat with typical localization on the face or lower limbs,
enlarged lymph nodes,
typical red and painful spots with jagged edges, similar to flames,
with rest the pain disappears.

The diagnosis is complemented by the detection of antibodies to streptococcus, as well as the identification of the pathogen.

Differential diagnosis is carried out with many skin diseases– phlegmons and abscesses, dermatitis, herpes zoster, eczema, erythema nodosum.

Treatment of erysipelas

Treatment is carried out by surgeons and therapists.

Hospitalization is not required, the disease is not contagious. It is necessary to increase fluid intake during fever, antipyretic drugs - Nurofen or paracetamol. Bed rest and diet are required.

Treatment includes taking antibiotics (erythromycin, ciprofloxacin, penicillins, cephalosporins) for at least 7-10 days. Treatment is supplemented with anti-inflammatory drugs (chlotazol, butadione); in case of intoxication, systems with glucose and isotonic solution are indicated.

Local therapy is necessary for the bullous form - dressings with furacillin and rivanol, for hemorrhages - dibunol. Ultraviolet irradiation is indicated; in the recovery stage, ozokerite, paraffin, calcium chloride.

Complications and prognosis

The main complications of erysipelas include sepsis, phlebitis and thrombophlebitis, damage to lymph nodes and blood vessels, and infectious-toxic shock.

The prognosis with timely initiation of treatment is favorable, on average, improvement occurs within 7-10 days, full recovery occurs within 2-3 weeks, but there may be relapses within two years.

Contents of the article

Erysipelas(synonyms for the disease: erysipelas of the skin) is an acute infectious disease caused by hemolytic streptococcus, characterized by fever and the formation of an inflammatory focus on the skin (less often on the mucous membranes) with clearly contoured edges and increased redness and pain from the center to the periphery. Has a tendency to recur.

Historical data of erysipelas

Erysipelas has been known since ancient times; Hippocrates described it in sufficient detail. J. Hunter, M.I. Pirogov noted the contagiousness of the disease. In 1882 p. Fehleisen isolated a pure culture of streptococcus from the affected skin of patients with beshikha. In the past in hospitals, maternity hospitals Outbreaks of erysipelas with high mortality were quite common. After introduction to medical practice sulfonamide drugs and antibiotics, erysipelas became sporadic.

Etiology of erysipelas

The causative agent of erysipelas is beta-hemolytic streptococcus, group A, which has 55 serovars, of which in our country they manifest mainly 1, 2, 4, 10 and 27. Streptococcus produces four types of erythrogenic toxin, as well as hyaluronidase, streptokinase, and protease. This facultative anaerobe, resistant to factors external environment. Sensitive to heat and action disinfectants. Quite a rare highlight lately hemolytic streptococcus from beshikhu patients is explained by its high sensitivity to chemotherapy, but this does not deny the role of streptococcus in the etiology of this disease.

Epidemiology of erysipelas

The source of infection is a person sick with beshikha, as well as healthy carriers of beshikha. hemolytic streptococcus. Patients with other streptococcal diseases - sore throat, scarlet fever, etc. - can be a source of infection. Infection occurs due to the penetration of the disease through damaged skin or mucous membranes. Morbidity - only in the form of sporadic cases.
The infectiousness of patients with beshikhu is insignificant. The highest incidence of beshikhu is in the second half of summer and early autumn. Women and older people are more likely to get sick.

Pathogenesis and pathomorphology of erysipelas

Hemolytic streptococcus penetrates both through damaged skin (exogenous route) and through the lymphogenous and hematogenous route from foci of acute and chronic streptococcal infection in the body. The formation of a focus of infection occurs against the background of already existing sensitization of the body to hemolytic streptococcus. The factor that leads to the occurrence of erysipelas is individual predisposition innate nature or one that arose as a result of repeated sensitization to streptococcus. In the origin of erysipelas, tissue biologically active substances play an important role next to streptococcal toxins. Hemorrhagic forms of the disease and persistent disorders of lymph circulation in the skin occur against the background of hyperhistamineemia and inhibition of histamine inactivation processes.
Primary and repeated (late relapse) beshikha is classified as a time-limited acute streptococcal disease, while recurrent (within 6 months) is classified as a chronic endogenous disease.
Early relapses of erysipelas occur due to the activation of endogenous (dormant) foci of infection in the skin, where beta-hemolytic streptococcus in the form of L-forms is stored in the cells of the mononuclear phagocyte system. Repeated erysipelas (late relapse) to the advantage of reinfection with other serovars of streptococcus. Relapses and recurrent illness Beshikh is promoted by a significant decrease in the secretion of glycocorticosteroids, impaired inactivation and increased formation of tissue biologically active substances, operations that lead to persistent disorders of lymph circulation, the development of fibrosis in the skin and subcutaneous tissue. Other protective and adaptive reactions of the body are also disrupted, which leads to chronicity infectious process. In turn, each new relapse of erysipelas further changes the body's reactivity, which creates the preconditions for the next outbreak of the disease.
Morphologically, erysipelas is characterized by serous or serous-hemorrhagic inflammation of the skin. With erythematous erysipelas, uneven thickening of the epidermis is manifested due to edema and areas of hyperplastic proliferation of cells of the spinous and basal layers. The swelling in the dermis is greater than in the epidermis. Vasodilation and perivascular infiltration by lymphoid and histiocytic cells are observed. With the occurrence of hemorrhages, the structure of the skin layers is disrupted, multiple hemorrhages appear in the epidermis and deep layers of the skin.
Bullous-hemorrhagic erysipelas is accompanied by pronounced edema, necrobiosis and tissue necrosis, resulting in hemorrhagic exudate.

Erysipelas clinic

Incubation period lasts from several hours to 3-5 days.
The following clinical forms of erysipelas are distinguished:
1) erythematous,
2) bullous,
3) hemorrhagic,
4) bullous-hemorrhagic.
Depending on the course, it can be primary, recurrent, repeated, and depending on the location - localized, migratory, or spreading, metastatic.
The disease begins acutely with chills, an increase in body temperature to 39-40 ° C. Patients complain of severe headache, general weakness, sometimes nausea and vomiting. Local manifestations of erysipelas appear simultaneously or after several hours, sometimes on the second day after the onset of the disease. In areas of the skin at the sites of future lesions, a feeling of fullness and pain appear, and after a few hours, pain in the regional lymph nodes occurs.
The period of the height of the disease coincides with the appearance of local changes. The inflammatory process is most often localized on the lower extremities, somewhat less often - on the face, rarely - on the upper extremities, very rarely - on the trunk, genitals, in the area mammary glands.

Erythematous erysipelas

First, a small pink spot appears on the skin, which spreads in one or more directions, and erythema is formed - the main symptom of this form of the disease. Erythema erysipelas is a limited area of hyperemic skin with uneven, clearly contoured edges in the form of teeth and tongues. The skin in this area is infiltrated, tense, hot to the touch, and moderately painful on palpation. Sometimes you can find a peripheral ridge in the form of infiltrated and raised edges of erythema. The color of erysipelas can vary from pink to intense red. Hyperemia and pain increase from the center to the periphery. At the beginning of the disease, redness disappears at the point of finger pressure. Later, due to skin infiltration and deep damage, this phenomenon disappears. When stroking the skin with a light touch (without pressure) simultaneously with the index and middle fingers - one along the edge of the area affected by erysipelas, and the other along the healthy one - there is a feeling of “pressure of the skin on the finger” in the area of erysipelas, which is not observed in the finger on the healthy one. skin (Andretz's symptom). Simultaneously with hyperemia and infiltration of the skin, its edema develops, spreading beyond the erythema, most pronounced in places with developed subcutaneous tissue (lips, eyelids, genitals, anterior abdominal wall). Given local signs faces are common to others clinical forms erysipelas with an erythematous background.

Bullous erysipelas

Bullous erysipelas develops within a few hours to 2-5 days from the onset of the disease. Against the background of erythema, bullous elements of various sizes appear - from small blisters to large blisters with serous fluid. The development of blisters is associated with the detachment of the epidermis from the dermis by exudate. As the blisters dry, brown crusts form. When the blisters are damaged, exudate leaks out. In their place, erosions appear, large eroded surfaces, and in severe cases, trophic ulcers.

Hemorrhagic erysipelas

Hemorrhagic erysipelas is characterized by the development, against the background of erythema, of hemorrhages in the skin of varying sizes - from petechial to confluent, sometimes over the entire area of erythema.

Bullous-hemorrhagic erysipelas

Bullous-hemorrhagic erysipelas is characterized by hemorrhagic syndrome with fibrinous-hemorrhagic exudate in the cavity of the blisters. All forms of erysipelas are accompanied by regional lymphadenitis and lymphangitis. Fever is one of the most constant manifestations of erysipelas. Body temperature reaches a maximum in the first 8-12 hours of illness; the duration of the febrile period when treating patients with antibiotics does not exceed 3-7 days. Mild forms of the disease usually occur with low-grade fever bodies. Heart sounds are muffled, pulse corresponds to body temperature, blood pressure decreases. Toxic damage nervous system manifested by headache, insomnia, apathy, vomiting, and sometimes meningeal syndrome. Oliguria, proteinuria are observed, and the urine sediment may contain erythrocytes, leukocytes, hyaline and granular casts.
From the blood side acute period disease, neutrophilic leukocytosis is detected, a shift leukocyte formula to the left, increase in ESR.
Erysipelas of the skin of the leg is the most common localization of the disease. Symptoms of general intoxication precede the development of local manifestations of inflammation, which, capturing most of the surface of the lower leg, quickly spreads along its posterior and lateral surfaces and more slowly through its anterior surface, bypassing the patella area.
Erysipelas develops during primary and repeated episodes of the disease. The most significant changes are observed if the cheeks, nose, and forehead are simultaneously affected. The inflammatory process spreads to the eyelids with significant swelling, narrowing of the palpebral fissures, and often the inability to open the eyes, which leads to facial distortion. Enlargement and tenderness of the submandibular lymph nodes often occur even before the development of changes in the skin. Erysipelas of the scalp is characterized by intense pain in the area of inflammation hidden by hair, skin infiltration and erythema are often absent.
Erysipelas of the upper extremities observed relatively rarely, develops mainly against the background of postoperative lymphostasis (elephantiasis) of the arm in women operated on for a breast tumor. The period between the formation of lymphostasis and the development of the disease may vary.
Erysipelas of the skin of the perineum and genital organs occurs with significant swelling in men - the scrotum and penis, in women - the labia majora. Erythema may spread to the pubic area and abdomen, less commonly to gluteal region and hips.
Erysipelas rarely occurs on mucous membranes; the inflammatory process, as a rule, spreads to them from adjacent areas of the affected skin. It is life-threatening to eat erysipelas of the pharynx and epiglottis.
Migrating (wandering) erysipelas caused by lymphogenous spread of infection, is a clinical variant of the common form of the disease and begins with a lesion distal section limbs. Lasts for weeks, sometimes months, often the inflammatory process returns to the previous location.
Metastatic erysipelas- the appearance of foci of skin inflammation remote from the primary lesion due to the hematogenous spread of streptococcal infection.
Periodic erysipelas It appears in some women during each menstruation, and with the onset of menopause, episodes of relapses continue instead of menstruation with great regularity.
Recurrent erysipelas observed quite often (in 20-80% of cases). This is a recurrence of the disease with localization inflammatory process in the area primary focus. Some individuals suffer dozens of relapses. Periods of remission between relapses range from several weeks to two years. Often relapses occur without significant intoxication with a short period of fever and atypical local manifestations. Manifestations of lymphostasis progress. The formation of chronic recurrent erysipelas is facilitated by inadequate treatment of the primary process, chronic diseases skin, especially mycoses, the presence of foci of chronic streptococcal infection, impaired lymph and blood circulation in the skin, working conditions with frequent hypothermia, microtrauma of the skin and other occupational hazards.
Repeated erysipelas occurs two years or more after the initial one, usually with a different localization of the process.
Virchow's "gelatinous" erysipelas is a recurrent erysipelas against the background of elephantiasis. The skin is blond-yellow, purple or brown. Erythema is slight. A clear boundary between the affected and healthy skin No.
White face of Rosenberg-Unn- a clinical type of erysipelas in patients with tuberculosis, syphilis, leprosy, eczema and some other diseases; The main manifestations are pain and severe swelling of the skin without redness. The absence of erythema is explained by intense exudation in the lymph nodes and compression of blood vessels.
Residual manifestations of erysipelas include peeling, pigmentation, and pasty skin. It is possible to develop lymphostasis, which is a consequence of erysipelas and can lead to elephantiasis.
Complications are observed in 2-10% of cases in the form of abscesses, phlegmon, ulcers, necrosis and gangrene of the skin, phlebitis and thrombophlebitis, suppuration of bullous elements. In weakened patients and elderly people, pneumonia, sepsis, acute failure blood circulation The consequence of recurrent erysipelas is secondary elephantiasis.
The prognosis for life is favorable in connection with widespread use antibiotics. With widespread bullous hemorrhagic erysipelas, skin necrosis, purulent complications recovery processes at the site of inflammation are significantly delayed, and therefore in some cases it is necessary surgery.

Diagnosis of erysipelas

Reference symptoms clinical diagnostics Erysipelas is an acute onset of the disease, fever, clearly limited redness of the affected area of the skin, sometimes with slightly raised edges, tension (infiltration) and soreness of the skin in the affected area, a positive Andretz sign, increased pain and redness from the center to the periphery, sometimes the presence of bullous elements.

Differential diagnosis of erysipelas

Differential diagnosis is made from erysipeloid, anthrax, phlegmon, thrombophlebitis, various dermatitis, burns, herpes zoster.
Erysipeloid (erysipelas of pigs) has a professional or natural focal nature. The process is usually localized on the skin of the fingers, the body temperature is normal or subfebrile, there are no signs of intoxication. At the site of the entrance gate of infection, erythema develops, often in the form of purplish-red plaques of various sizes, often with a light purple tint. The edges of the erythema are brighter compared to the center, where the skin may have a normal color. Anamnesis data indicate microtraumas during processing of meat, poultry, and fish. Staying in natural relatively erysipeloid cells decides the diagnosis.
In patients with anthrax, unlike erysipelas, changes in the skin develop in stages, a characteristic painless carbuncle (black scab) is formed, and symptoms of intoxication gradually increase. The process is most often localized on the upper extremities.
Cellulitis is characterized by a bluish-purple hue, redness of the skin without clear boundaries, severe pain at the site of phlegmon localization, increased redness and pain from the periphery to the center, dense nature of the deep infiltrate, sharp pain on palpation and movements, negative symptom Andretz.
Thrombophlebitis begins with pain along the vessels of the affected limb, which further intensifies and swelling appears. There is redness of the skin in the form of spots and gravitates over the affected veins. On palpation, they are dense and painful; painful compactions in the form of nodes (nodules) are possible, sometimes with redness of the skin over them.
In patients with dermatitis, small blisters, scales, and crusts appear against the background of erythema; feeling of heat in the affected area and burning pain No. Unlike erysipelas, there is NO regional lymphadenitis or signs of intoxication. The medical history often includes information about contact with various chemical and physical irritants, some of which may be allergens - medications, paints, varnishes, washing powders, perfumes, disinfectants.
Herpes zoster begins with pain or burning along the nerve trunks, fever. Erythema develops, followed by a rash of numerous blisters with serous or hemorrhagic contents. The rash is characterized by segmental, often asymmetric localization along the nerve trunks.

Treatment of erysipelas

Patients with primary, repeated beshikha, as well as in case of early relapses, are prescribed benzylpenicillin every 3 hours: mild forms - 100,000-200,000 units / kg per day, severe - 300,000-400,000 units / kg per day. The duration of treatment is at least 7-10 days.
In case of frequent relapses, two courses of antibiotic therapy are carried out with an interval of 7-10 days using drugs that were not previously prescribed to the patient - lincomycin, oxacin, ampicillin, methicillin. The first course is 10 days, the second is 7-8 days with a change of drug. It is advisable to carry out a repeated course of treatment with lincomycin, since this drug is effective against L-forms of hemolytic streptococcus. For the purpose of anti-relapse treatment, the administration of bicillin-5 at 1,500,000 units once a month is indicated for 1-1.5 years after discharge from the hospital. During this time regular forms streptococci, which are constantly formed from L-forms in the body, are destroyed by an antibiotic (Biocillin), which ensures the liberation of the body from L-forms of streptococcus.
If relapses of erysipelas are frequent, glycocorticosteroids are also used. Prednisolone is prescribed in a daily dose of 30 mg with a gradual reduction (course dose 350-400 mg). In the presence of persistent infiltration, non-steroidal anti-inflammatory drugs (butadione, Reopirin, chlotazol, etc.) are indicated for 10-15 days. Treatment with these drugs begins simultaneously with antibiotics and continues to reverse the development of local inflammatory changes.
In the case of a sluggish or sluggish and protracted course of the disease, to stimulate the body’s natural defenses, it is recommended to use autohemotherapy, prescribe methyluracil, pentoxyl, as well as B vitamins, rutin, and ascorbic acid.
Erythematous erysipelas does not require use local funds treatments that only irritate the skin and enhance exudation processes (especially Vishnevsky ointment, ichthyol ointment, etc.). Large bubbles carefully cut from one edge and make applications with a solution of rivanol (1:1000) or furatsilin (1:5000). In patients with frequent relapses erysipelas, and the presence of persistent lymphostasis, regional lymphadenitis local treatment alternates with physiotherapeutic procedures - UHF therapy, ultraviolet irradiation, using radon baths, B initial stage formation of elephantiasis, the administration of lidase, which suppresses the collagen-resolving function of fibroblasts, is indicated. For persistent infiltrates that do not resolve, ultrasound is used.

Prevention of erysipelas

In persons prone to beshikhu disease, careful treatment of concomitant diseases of the skin, peripheral vessels, mycoses of the feet, chronic venous insufficiency, as well as rehabilitation of foci of chronic streptococcal infection - tonsillitis, otitis, sinusitis, dental caries. It is necessary to carefully observe personal hygiene, prevent microtrauma, abrasion, Oprah's mercy, hypothermia and the like. Persons with frequent relapses of erysipelas, as well as with pronounced residual manifestations of the disease, are subject to dispensary observation, year-round bicilinoprophylaxis.

Erysipelas is an acute infectious disease caused by group A streptococcus, which is characterized by skin lesions and the presence of bright pronounced syndrome intoxication.

Modern classification is divided according to the following parameters:

by flow rate;
by the nature of local manifestations;
by the prevalence of local lesions;
according to severity.

By flow rate

The most common localization of erysipelas is the skin of the face and lower extremities.

Primary erysipelas (occurring for the first time; the most common place for its localization is the face).
Repeated erysipelas (occurring later than 2 years after the initial case or earlier than this period, but with a different localization).
Recurrent erysipelas (occurring from several days to 2 years after the initial case, but with the same localization of the inflammatory process, or later than 2 years, but with previous frequent relapses during this period; most often occurs on the skin of the extremities). Relapses can be early (occurring in the first 6 months) and late, frequent (more than 3 times a year) and rare. If the disease recurs more than 4-5 times during the year, it becomes chronic.

According to the nature of local manifestations

Erythematous form. After 5–10 hours from the onset of the disease, itching, a burning sensation, fullness, pain, and soreness when touched appear in a certain area of the skin. After a short period of time, swelling and thickening appear in the affected area, the skin turns red, forming a bright spot with uneven boundaries that look like flames. Along the edges of the spot, the skin rises, forming an infiltration ridge. Besides skin manifestations This form of the disease is characterized by varying degrees severity of intoxication syndrome with fever for 6–7 days, regional damage to the lymph nodes in the form of their enlargement, hardening and the appearance of pain on palpation.
Erythematous-bullous form. Against the background of redness, bubbles and blisters filled with colorless contents form. Subsequently, they open spontaneously or with the help of sterile scissors, their contents expire, the upper dead layer of skin peels off, and in its place crusts form, which after a while fall off, leaving no scars. The phenomena of intoxication and lymphadenitis are also present.
Erythematous-hemorrhagic form. Happens quite often. With this form, against the background of redness, there are hemorrhages ranging in size from 1–2 millimeters to several centimeters. Also characterized by a longer duration of fever – up to 2 weeks – and a slow reverse development of the process with the formation of necrotic changes on the skin.
Bullous-hemorrhagic form. The heaviest. A feature of this form of the disease is the presence of blisters against the background of erythema with serous-hemorrhagic contents, caused by damage to small vessels of the skin. After opening, ulcerations and erosions form at the site of the blisters, leaving behind areas of necrosis and scars.

According to the prevalence of local lesions

Localized - if the source of inflammation does not extend beyond one anatomical area - face, back, lower leg.
Common - several anatomical areas are involved in the pathological process (for example, the thigh and lower leg).
Migrating (wandering, creeping) - the subsidence of inflammation in one area of the skin is accompanied by its development in another.
Metastatic - foci of inflammation are located on areas of the skin distant from each other (for example, on the face and lower legs).

By severity

Mild - this form is characterized by short-term (1-3 days) fever with a temperature rise not exceeding 39ºC, unexpressed other symptoms of intoxication, and an erythematous localized form of skin manifestations.
Moderate severity - characterized by fever for 4-5 days, the temperature reaches 40ºC, other symptoms of intoxication are quite pronounced (there is severe weakness, headache, there may be nausea, vomiting); widespread skin lesions of erythematous, erythematous-bullous or bullous-hemorrhagic form.
Severe - fever with figures of 40ºC and above lasts more than 5 days, severe intoxication (up to the loss of consciousness of the patient), bullous-hemorrhagic and erythematous-bullous skin lesions, accompanied by complications in the form of gangrenous changes, phlegmon, infectious-toxic shock and even sepsis

Features of the disease

Erysipelas is often accompanied by an increase in body temperature to febrile levels.

Most frequent place localizations of erysipelas are skin lower extremities, slightly less frequently, lesions appear on the face and upper extremities; in some cases they can be observed on the skin of the torso.

Children get sick infrequently and in a mild form.

Elderly people experience primary and recurrent erysipelas quite hard, with fever for up to 1 month and exacerbation of concomitant diseases. Their local manifestations also regress slowly.

Which doctor should I contact?

If a skin lesion appears, you should consult a dermatologist. In cases of recurrent erysipelas that are difficult to treat, consultation with an infectious disease specialist and an immunologist will be useful.