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Cellulitis - Hair and Scalp
See also in: Overview,Cellulitis DDx,Anogenital,Oral Mucosal Lesion
Other Resources UpToDate PubMed

Cellulitis - Hair and Scalp

See also in: Overview,Cellulitis DDx,Anogenital,Oral Mucosal Lesion
Contributors: Negar Esfandiari MD, Sabrina Nurmohamed MD, Mary Gail Mercurio MD, Susan Burgin MD, Paritosh Prasad MD
Other Resources UpToDate PubMed

Synopsis

Cellulitis is a common bacterial infection of the deep dermis and subcutaneous tissue characterized by erythema, pain, warmth, and swelling. Pathogens causing cellulitis are strongly correlated with age and immune status:
  • Immunocompetent adults: common etiologies include Staphylococcus aureus (particularly if there is concurrent purulence) and Streptococcus pyogenes.
  • Immunocompromised individuals: common pathogens such as S aureus and Streptococcus should be considered, but gram-negative pathogens should also be considered and covered.
  • Diabetic foot infections and decubitus ulcers: consider a mixture of gram-positive cocci and gram-negative aerobes and anaerobes.
  • Aquatic soft tissue injury: Vibrio spp, Aeromonas spp, Mycobacterium marinum, etc.
A focused history should determine immune status, comorbid conditions, possible sites and causes of skin barrier disruption, prior history of cellulitis, and methicillin-resistant S aureus (MRSA) risk factors, as well as community prevalence of MRSA. The most common route of bacterial seeding in immunocompetent individuals is via direct inoculation, and in immunocompromised individuals, it is via hematogenous seeding.

Risk factors for developing cellulitis include minor skin trauma, atopic dermatitis, contact dermatitis, body piercings, intravenous (IV) drug use, tinea pedis infection, animal bites, peripheral vascular disease, obesity, older age, immune suppression (chronic systemic steroid use, neutropenia, immunosuppressive medications, organ transplantation, HIV), and lymphatic damage (lymph node dissection, radiation therapy, vein harvest for coronary artery bypass surgery / saphenous venectomy, and damage that occurs following multiple prior episodes of cellulitis).

Fevers, chills, and malaise may precede the onset of cellulitis but may also be absent. Poorly defined borders, erythema, swelling, tenderness, and warmth characterize typical cellulitis lesions. In adults, the extremities, particularly the lower extremities, are the most common sites affected. In more severe cases, additional clinical features may include vesicle and bullae formation, pustules, and necrosis. Complications are not common but can include glomerulonephritis, lymphadenitis, and bacteremia.

A rising prevalence of MRSA has been identified as a pathogen of skin and soft tissue infections in otherwise healthy individuals lacking the aforementioned risk factors for cellulitis. MRSA should be considered for penetrating traumas, purulent infections, and in specific populations: athletes, children, prisoners, military service members, long-term care residents, and IV drug users. Other MRSA risk factors include recent admission to a health care facility, presence of an indwelling catheter, poor personal hygiene, and history of MRSA.

Recurrent Cellulitis: Major risk factors for recurrent cellulitis include chronic edema, dermatomycosis, and lymphatic or venous insufficiency. Prior episodes of cellulitis, immunodeficient states, obesity, previous local surgery / saphenectomy, as well as having cancer, can also increase the risk of recurrent cellulitis.

Related topics: orbital cellulitis, preseptal cellulitis

Codes

ICD10CM:
L03.90 – Cellulitis, unspecified

SNOMEDCT:
128045006 – Cellulitis

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Cellulitis can be caused by many different bacterial pathogens, but the diagnosis is almost always made clinically. If a patient has had more than 1 episode of cellulitis, investigate risk factors for recurring cellulitis but also consider alternative diagnoses.

The differential for cellulitis is vast, and time course, drug / exposure history, and the presence / absence of systemic features should help delineate the cause. The differential diagnosis for suspected cellulitis of the head / scalp includes:
  • Tinea capitis (see Favus, Kerion)
  • Herpes zoster
  • Acne keloidalis nuchae
  • Dissecting cellulitis of scalp
  • Folliculitis decalvans
  • Central centrifugal cicatricial alopecia
  • Lichen planopilaris
  • Pseudolymphoma
  • Inflamed or infected Pilar cyst
  • Psoriasis
  • Discoid lupus erythematosus
  • Pityriasis amiantacea
  • Erosive pustular dermatosis
  • Angiosarcoma of skin
  • Cryptococcosis
  • Occipital neuralgia

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Management Pearls

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Therapy

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References

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Last Reviewed:03/14/2023
Last Updated:04/02/2023
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Cellulitis - Hair and Scalp
See also in: Overview,Cellulitis DDx,Anogenital,Oral Mucosal Lesion
A medical illustration showing key findings of Cellulitis (General) : Chills, Lymphadenopathy, Lymphangitis, Skin warm to touch, Unilateral distribution
Clinical image of Cellulitis - imageId=51043. Click to open in gallery.  caption: 'Linear erythematous plaques on the thigh (lymphangitis) indicating proximal spread of a more distal cellulitis.'
Linear erythematous plaques on the thigh (lymphangitis) indicating proximal spread of a more distal cellulitis.
Copyright © 2024 VisualDx®. All rights reserved.