How often do we see patients in clinic who have a history of leg cellulitis? Do we always realise how important a role we have as podiatrists? What advice should we give to help reduce its recurrence? This article briefly looks at a recent survey of patients highlighting some of the gaps in their knowledge and how we, as healthcare professionals, may be able to help fill them.
What is cellulitis?
Cellulitis is a serious bacterial infection of the leg which is increasing in frequency. In 2017-2018, there were nearly 89 000 patients admitted to hospital for the condition with affected patients occupying 1% of all hospital beds in England and Wales (1). In 2018, I wrote a CPD article for Podiatry Now (click here to download) covering essentials of the disease. It presents as a hot, swollen tender leg (with or without lymphangitis and lymphadenopathy). In virtually all cases patients feel unwell with flu-like symptoms. The disease can damage the lymphatics leaving the leg permanently swollen and open to recurrent attacks of the disease.
Risk factors for the development of the disease include (2):
Previous episodes of cellulitis
Open wounds
Current leg ulcers
Lymphoedema/chronic leg oedema
Excoriating skin diseases (cracked heels or callus)
Tinea pedis / Onychomycosis
Increased body mass index (BMI> 30 kg/m2)
Diabetes
Treatment for many patients with the disease is with long term antibiotics which, in turn, can lead to concerns about bacterial resistance. Consequently, non-antibiotic methods of prevention are always being sought. Although formally under researched, modifications to any of the risk factors may have a protective effect.
In a recent study published in the British Journal of Dermatology (3) a team have explored patients views and knowledge about their condition. Using a patient survey (with 240 responders) and thirty in-depth interviews, researchers interviewed adults who had suffered one or more bouts of the disease. The results uncovered mixed beliefs about the aetiology of the condition including the misconception of ageing as a cause. A significant proportion (42%) were unaware of their increased risk of cellulitis recurring. Even more respondents (66%) were not aware of measures that they could adopt to reduce the likelihood of recurrence. Only one-third of patients were were willing to take long term antibiotics to protect from further episodes. Interestingly though, 66% were in favour of other non-antibiotic based measures such as improved foot hygiene, compression stockings, weight loss and increasing the amount of daily activity.
What can we do to help?
The results from this survey are positive but highlight that the message about cellulitis and measures to prevent recurrence is not widely known by patients. As podiatrists what can we do to help? As mentioned in my CPD article, there are a number of things that can reduce the risk of recurrence.
In the prevention of the disease, the podiatrist can play a significant role and reduce the risk of further episodes. The condition is known to occur more frequently in older patients (4) and those with diabetes are likely to suffer increased morbidity and prolonged hospital admissions than those without (5).
Bristow I. R. (2018) “Cellulitis of the leg.”
Emollients & Callus Reduction
Basic skin care remains the mainstay for patients with a history of the disease. As skin breakage remains a leading risk factor for cellulitis development maintaining its integrity should be paramount. Like prevention in the diabetic foot, the aim of treatment should be to prevent skin compromise and ulceration as this may allow the ingress of cellulitis causing bacteria. Simple reduction of callus on the plantar surface and around the heels can prevent cracking and fissuring. Education on the use of moisturisers to the feet and legs should also be utilized. Emollients containing urea are particularly effective in maintaining skin flexibility and enabling thinning of plantar and heel hyperkeratosis (6).
Interdigital Hygiene
Interdigital hygiene cannot be over-emphasised. Evidence has highlighted how this area is a potential portal of entry. Reduction of any maceration is advised with simple astringents thereby reducing fungal and bacterial populations known to increase the risk of the disease. The use of topical miconazole has been shown to have efficacy against gram positive organisms such as Streptococci (including Strep. Pyogenes) and Staphylococcus at concentrations well below those found in off the shelf topical formulations [1%] (7). Alternatively, the regular use of hypochlorous solution soaks interdigitally may help to maintain hygiene in this area (see previous article here).
Reducing Tinea Pedis
In addition, patients should be educated to recognise the early signs of tinea pedis. Many patients are unaware of the presence of their infection (8) due to the lack of symptoms such as itching (9). Patients should be advised to pay attention to the interdigital areas where fungal infection has been shown to pose the highest risk for the development of lower limb cellulitis (10, 11) but also not forget the plantar surface. Based on the evidence available, active treatment in patients with a history of cellulitis, for any onychomycosis is also advisable, when appropriate.
The prophylactic use of antifungal agents on the skin of the foot may help reduce the recurrence of tinea (12, 13). A typical regime would be fortnightly applications of two days of terbinafine hydrochloride 1% as it is able to reside in the skin longer after application than the imidazoles such as clotrimazole and miconazole.
References
1. Levell NJ. Cellulitis: how can we know what patients don't know? Br J Dermatol. 2019;180(4):705-6.
2. Quirke M, Ayoub F, McCabe A, Boland F, Smith B, O'Sullivan R, et al. Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol. 2017;177(2):382-94.
3. Teasdale EJ, Lalonde A, Muller I, Chalmers J, Smart P, Hooper J, et al. Patients’ understanding of cellulitis and views about how best to prevent recurrent episodes: mixed-methods study in primary and secondary care. Br J Dermatol. 2019;180(4):810-20.
4. McNamara DR, Tleyjeh IM, Berbari EF, Lahr BD, Martinez JW, Mirzoyev SA, et al. Incidence of lower-extremity cellulitis: a population-based study in Olmsted county, Minnesota. Mayo Clin Proc. 2007;82(7):817-21.
5. Musette P, Benichou J, Noblesse I, Hellot MF, Carvalho P, Young P, et al. Determinants of severity for superficial cellulitis (erysipelas) of the leg: a retrospective study. European journal of internal medicine. 2004;15(7):446-50.
6. Bristow IR. Urea - the gold standard for emollients? Podiatry Now. 2016;19(10):20-3.
7. Nenoff P, Koch D, Krüger C, Drechsel C, Mayser P. New insights on the antibacterial efficacy of miconazole in vitro. Mycoses. 2017;60(8):552-7.
8. Mayser P, Hensel J, Thoma W, Podobinska M, Geiger M, Ulbricht H, et al. Prevalence of fungal foot infections in patients with diabetes mellitus type 1 - underestimation of moccasin-type tinea. Exp Clin Endocrinol Diabetes. 2004;112(5):264-8.
9. Maruyama R, Hiruma M, Yamauchi K, Teraguchi S, Yamaguchi H. An epidemiological and clinical study of untreated patients with tinea pedis within a company in Japan. Mycoses. 2003;46:208-12.
10. Dupuy A, Benchikhi H, Roujeau J-C, Bernard P, Vaillant L, Chosidow O, et al. Risk factors for erysipelas of the leg (cellulitis): case-control study. Brit Med J. 1999;318(7198):1591-4.
11. Bjornsdottir S, Gottfredsson M, Thorisdottir AS, Gunnarsson GB, Rikardsdottir H, Kristjansson M, et al. Risk factors for acute cellulitis of the lower limb: a prospective case-control study. Clin Infect Dis. 2005;41(10):1416-22.
12. Shemer A, Gupta AK, Kamshov A, Babaev M, Farhi R, Daniel CR, et al. Topical antifungal treatment prevents recurrence of toenail onychomycosis following cure. Dermatologic Therapy. 2017;30(5).
13. Tosti A, Elewski BE. Onychomycosis: Practical Approaches to Minimize Relapse and Recurrence. Skin Appendage Disord. 2016;2(1-2):83-7.