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Module 4.4: Infection
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Treatment for Cellulitis

CKS NICE (2023) recommendations for managing acute cellulitis are that only people with mild or moderate cellulitis without systemic symptoms should be managed in primary care.

Admission to hospital may be necessary if the person:

  • Has Class IV cellulitis (sepsis or severe life-threatening infection, such as necrotising fasciitis).
  • Has Class III cellulitis (significant systemic upset, such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable comorbidities, or a limb-threatening infection due to vascular compromise).
  • Has severe or rapidly deteriorating cellulitis (for example extensive areas of skin).
  • Is very young (under 1 year of age) or frail.
  • Is immunocompromised.
  • Has significant lymphoedema.
  • Has facial cellulitis (unless very mild).
  • Has suspected orbital or periorbital cellulitis (admit to ophthalmology).
  • Has Class II cellulitis (systemically unwell or systemically well but with a comorbidity).
  • Admission may not be necessary if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the person (check local guidelines).
  • Has symptoms or signs suggesting a more serious illness or condition (such as osteomyelitis, or septic arthritis).

It also recommends referring people to hospital, or seek specialist advice, if they:

  • Are severely unwell.
  • Have infection near the eyes or nose (including periorbital cellulitis).
  • Could have uncommon pathogens, for example, after a penetrating injury, exposure to water-borne organisms, or an infection acquired outside the UK.
  • Have spreading infection that is not responding to an oral antibiotic.
  • Have lymphangitis.
  • Cannot take oral antibiotics (exploring locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where appropriate).

CKS NICE (2023) recommend that patients managed in primary care should be prescribed a high dose of oral antibiotics. If possible, an outline of the extent of the infection should be made with a permanent marker pen. This aids observation, comparison and tracking of the spread of infection.

Advise the patient to:

  • Take paracetamol or ibuprofen for pain and fever
  • Drink adequate fluids to prevent dehydration
  • Elevate the leg/limb for comfort and to relieve oedema (where applicable)
  • Use a bed cradle (where applicable)
  • Seek immediate advice if antibiotics are not tolerated, the cellulitis becomes worse, or if systemic symptoms develop or worsen (such as high temperature, or nausea and vomiting)
  • Avoid the use of compression garments

(CKS NICE, 2023; PCDS, 2023)

Dry cellulitis

Dry cellulitis should not be cleansed, as being very erythematous, oedematous and acutely painful, this would increase the risk of infection (Beldon & Burton, 2005). The inflamed area should be marked to monitor spreading infection as spreading infection may spread to the lymphatic system, the lymph nodes, the blood stream or deeper tissues (Rowland, 2002). As the infection and swelling reduces, the skin will become very dry and scaly and will slough off, so will need regular moisturising.

Wet cellulitis

The impact of cellulitis on skin is to cause tension and swelling, which in some cases leads to ulceration and loss of large amounts of exudate (CREST, 2005). This is also known as wet cellulitis. Dressing products should be used to control exudate and protect surrounding skin from breakdown. Topical antibiotics are not recommended for the management of cellulitis (CREST, 2005).

Dressings available for wet cellulitis include:

  • Non-adherent contact layer
  • Non-adhesive foam dressings
  • It is inadvisable to use adhesive bordered dressing as this may further irritate the skin (Beldon, 2011)
  • Alginate dressings
  • Hydrofiber dressings
  • Hydration response dressings/superabsorbent dressings

(Beldon, 2005)