The Australasian College of Dermatologists
Recommendations from the Australasian College of Dermatologists on leg cellulitis, epidermal cysts, urticaria, distorted toenails & acne. The Australasian College of Dermatologists was established in 1966 as the medical college responsible for the training and professional development of medical practitioners in the speciality of dermatology.
Do not assume that bilateral redness and swelling of both lower legs is due to infection unless there is clinical evidence of sepsis such as malaise, fever and neutrophilia, plus an expanding area of redness or swelling over a period of hours to days.
Bilateral lower leg cellulitis is very rare. Most commonly the redness is due to an underlying inflammatory skin disorder such as venous eczema or a more deeply extending inflammation involving the subcutaneous fat known as lipodermatosclerosis. This condition, which occurs more frequently in patients with venous disease, who are overweight and immobile, may initially present as bilateral redness and swelling, and then progresses over time to produce scarring and hardening of the underlying tissues. A careful history and physical examination should be undertaken. An entry point for infection should be looked for, and swabs taken from open skin wounds. However, microbiological testing from intact overlying skin is usually of little value.
- Hirschmann JV, Raugi GJ. Lower limb Cellulitis and its mimics: part I. Lower limb cellulitis. Journal of the American Academy of Dermatology 2012;67(2):163e1-163e12.
- Hirschmann JV, Raugi GJ. Lower limb Cellulitis and its mimics: part II. Conditions that simulate lower limb cellulitis. Journal of the American Academy of Dermatology 2012; 67(2):177.e1-177.e9.
- Levell NJ, Wingfield CG, Garioch JJ. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. British Journal of Dermatology 2011;164(6):1326-8.
- Arakaki RY, Strazzula L, Woo E, Kroshinsky D. The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial. JAMA Dermatology 2014;150(10):1056-61.
A long-standing College Fellow, in consultation with the Honorary Secretary has prepared 5 recommendations. All ACD members were invited to choose three out of the five recommendations. Following an NPS Representatives meeting, it was noted that five recommendations are needed. Therefore the remaining two recommendations were selected.
- 1 Do not assume that bilateral redness and swelling of both lower legs is due to infection unless there is clinical evidence of sepsis such as malaise, fever and neutrophilia, plus an expanding area of redness or swelling over a period of hours to days.
- 2 Do not routinely prescribe antibiotics for inflamed epidermoid cysts (formerly called sebaceous cysts) of the skin.
Acute urticaria (i.e. of less than 6 weeks duration) does not routinely require investigation for an underlying cause. Where clinical history and examination suggest the possibility of a bacterial infection or food as a likely trigger, further testing may be warranted. If individual lesions (weals) persist for longer than 24 hours an alternative diagnosis may need to be considered.
- 4 Do not prescribe topical or systemic anti-fungal medication for patients with thickened, distorted toenails unless mycological confirmation of a dermatophyte infection has been obtained.
- 5 Monotherapy for acne with either topical or systemic antibiotics should be avoided.