Generally accepted classification
In clinical practice, the classification by V.L. Cherkasov (1986) is traditionally used. It divides the disease into four key criteria, allowing for a precise diagnosis and determination of management tactics.
1. By the nature of local manifestations:
- erythematous;
- erythematobullous;
- erythematohemorrhagic;
- bullous-hemorrhagic.
2. By the severity of intoxication and process:
- mild (I);
- moderate (II);
- severe (III).
3. By the frequency of the course:
- primary;
- recurrent (occurs in patients who have not had previous relapses, or if a new lesion appears in a completely different anatomical area);
- relapsing (recurrence of the process in the same localization). Relapses are divided into frequent (from 3 times a year), early (in the first 6 months), and late (after more than half a year).
4. By the prevalence of inflammation:
- localized (within the boundaries of a single anatomical region);
- disseminated (involving multiple regions);
- metastatic (an extremely rare form with hematogenous seeding and the appearance of distant foci, e.g., spreading from the lower leg to the face).
Features of local forms of erysipelas
The morphological basis of the local focus is microcirculation disorders: blood and lymph stasis, plasmarrhagia, and thrombosis of lymphatic pathways. Depending on the depth and nature of the lesion, four main forms are distinguished.
Erythematous erysipelas
Occurs as an independent form or precedes more complex changes. Against the background of acute intoxication, bright hyperemia forms. The lesion is hot, elevated above healthy skin, has clear irregular contours ("flame tongues" or "geographic map") and a peripheral infiltrative border. The skin is glossy, and moderate tenderness is noted upon palpation.
Erythematobullous erysipelas
Forms a few hours or 2–5 days after the onset of erythema. Due to abundant exudate transudation, epidermal cells swell, and intercellular connections rupture. Epidermal detachment occurs with the formation of blisters (bullae). The content of the bullae is serous. Subsequently, the blisters either rupture to form erosions or dry into dense yellow-brown crusts.
Erythematohemorrhagic erysipelas
Develops on days 1–3 from the onset of erythema. Characterized by the appearance of hemorrhages within the lesion—from pinpoint petechiae to extensive confluent spots. This is due to increased permeability and damage to small dermal vessels.
Bullous-hemorrhagic erysipelas
The most severe local variant. It transforms from erythematobullous or erythematohemorrhagic forms as a result of deep damage to the capillaries of the reticular and papillary layers. The bullae acquire a dark color, filled with fibrinous-hemorrhagic exudate. Complications in the form of necrosis with secondary suppuration and ulcer formation are possible.
Severity criteria
The severity of the patient's condition is assessed by the severity of fever, intoxication, the area of the local lesion, and the presence of complications.
| Grade | Intoxication and fever | Local process and hemodynamics |
|---|---|---|
| Mild (I) | Insignificant, subfebrile temperature | Localized lesion, mostly erythematous |
| Moderate (II) | Chills, weakness, myalgia, nausea, temperature 38–40°C | Localized or disseminated lesion. Tachycardia and arterial hypotension are possible |
| Severe (III) | Hyperthermia >40°C, intense headache, repeated vomiting, convulsions, clouding of consciousness | Acute cardiovascular failure. This also includes the bullous-hemorrhagic form with extensive blisters regardless of temperature |
Dependence of clinical presentation on localization
The anatomical location of the lesion significantly affects the course of the disease and prognosis.
- Lower extremities (60–70%). The most frequent zone of involvement. Hemorrhagic forms with large blisters and skin defects most commonly develop here. Involvement of the lymphatic system (lymphangitis, regional lymphadenitis) is characteristic. The process tends to a chronic relapsing course, especially against the background of underlying lymphovenous insufficiency or mycoses.
- Face (20–30%). Occurs as a primary or recurrent form (frequent relapses are rare). Intoxication and the local lesion appear almost simultaneously. It proceeds easier than erysipelas of the legs. Provoking factors are often ENT pathology, dental caries, and tonsillitis. A distinctive diagnostic sign is a pale, untouched nasolabial triangle.
- Upper extremities (5–7%). A specific localization that often develops in women against the background of postoperative lymphedema (e.g., after mastectomy). It is distinguished by a persistent relapsing character.
Briefly: answers to topical questions
Which microorganism is the main causative agent of erysipelas?
The main causative agent of erysipelas is group A beta-hemolytic streptococcus (GABHS) of any serological types.
The sources indicate the forms of existence of the pathogen:
- bacterial forms;
- L-forms.
Pathogenicity factors of bacterial forms include exotoxins, toxins, enzymes, and antigens. In recurrent erysipelas during remission, L-forms of streptococcus persist predominantly in skin macrophages and regional lymph nodes.
GAS is described as having a hyaluronic acid capsule: it protects against phagocytosis and facilitates adhesion to the epithelium. Hyaluronidase is also noted as an invasion factor, and C5a peptidase suppresses the chemotaxis of polymorphonuclear leukocytes and macrophages.
What general and local complications can develop in the course of erysipelas?
Local and general complications can develop in erysipelatous inflammation.
- Local complications: abscesses, phlegmons, skin necrosis, pustulation of bullae, phlebitis, thrombophlebitis, lymphangitis, periadenitis. They occur more frequently in the bullous-hemorrhagic form. In thrombophlebitis, superficial veins and, less commonly, deep veins of the leg are affected.
- General complications: sepsis, infectious-toxic shock (ITS), acute cardiovascular failure, pulmonary embolism (PE). Sources indicate a low frequency for general complications: 0.1–0.5%.
Which groups of antibacterial drugs are used for etiotropic treatment of erysipelas?
For etiotropic treatment, sources indicate high sensitivity of most strains, especially S. pyogenes, to the following antibiotics/groups:
- penicillins;
- macrolides;
- chloramphenicol.
EBEB is an acronym for remembering the four forms of the local process in order of increasing severity: Erythematous, erythematous-Bullous, Erythematous-hemorrhagic, Bullous-hemorrhagic.
Class and exam questions
Does a red spot always appear on the first day of the disease?
No, in more than half of the cases (especially with lower limb involvement), acute intoxication syndrome with high fever and chills precedes local manifestations by several hours or even 1–2 days.
Can the diagnosis of "erysipelas" be made in the presence of severe spontaneous pain in the lesion?
Uncomplicated erysipelas is characterized only by moderate tenderness upon palpation of the lesion and intact lymph nodes. The presence of intense, spontaneous pain at rest indicates complications (abscess, phlebitis) or surgical pathology.
What is the difference between recurrent and repeated erysipelas?
A recurrent form is a repeat of the disease with the same localization of the inflammatory lesion. If erysipelas occurs for the first time in many years or the lesion appears in a new anatomical area (e.g., previously on the leg, now on the face), it is regarded as a subsequent (second/new) form.
What else to study on this topic
- Pathogenesis of persistent lymphostasis and secondary elephantiasis (fibredema)
- Differential diagnosis of erysipelas with urgent surgical infection (abscesses, phlegmons)
- Features of hemogram and urinary sediment changes in the acute period
- Specifics of differentiating swine erysipelas (erysipeloid) from contact dermatitis
- Causes and types of complications: local (necrosis, phlebitis) and general (PE, ITS)
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