Erysipelas in adults: Pathogenesis, risk factors, diagnosis, treatment and prevention, with emphasis on Paraguay and Spain

Abstract

Introduction: Erysipelas is an acute bacterial infection of the superficial dermis and lymphatic vessels, almost always caused by β-hemolytic streptococci, that mainly affects the lower limbs and represents a considerable health burden. Despite its frequency, specific epidemiological information is scarce and management guidelines come mostly from high-income settings. The aim was to synthesize evidence on pathogenesis, risk factors, diagnosis, treatment and prevention of erysipelas in adults, and to compare management described in Paraguay and Spain. Materials and methods: Narrative review of evidence published through March 2025. Results: Case-control studies consistently show that the main determinants are local —lymphedema, interdigital intertrigo, wounds, ulcers and previous episodes—, whereas diabetes has not been confirmed as an independent acquisition factor, although it worsens the course and is associated with recurrence. Diagnosis is clinical; up to one third of cases admitted as leg cellulitis are actually other dermatoses, with avoidable antibiotics and hospitalization. First-line treatment is a beta-lactam directed at streptococcus, and in uncomplicated disease five days are equivalent to ten. Recurrence is reduced by treating predisposing factors, prophylactic penicillin —whose effect wanes when discontinued— and compression therapy in chronic leg edema. Management in Paraguay and Spain is essentially similar, and the main shared gap is the absence of country-specific epidemiological data on erysipelas. Conclusions: Erysipelas is diagnosed and treated simply, but prevention requires sustained attention to local risk factors.