Erysipelas:
red skin, fever, penicillin — and how to prevent it coming back

1. What is erysipelas?

Erysipelas is an acute bacterial infection of the dermis (the deeper layer of the skin) that spreads along the fine lymphatic spaces and vessels. It is almost always caused by beta-haemolytic streptococci, mostly group A (Streptococcus pyogenes), less often groups B, C or G.^¹ These are the same bacteria that can also cause scarlet fever — except that here they get in through a small break in the skin.

The typical sign is sudden, sharply defined, bright red redness that feels warm, often with tongue-like extensions. Unlike many other skin problems, the whole body reacts: fever, chills and feeling unwell are part of it from the start.^¹ The lower leg is affected most often, followed by the face.

2. Forms: from classic to necrotising

3. Symptoms and complications

• Fever and chills: often the first sign, sometimes hours before the skin turns red. More on fever and chills.^¹
• Redness: bright red, shiny, sharply defined, often with tongue-like extensions; it usually starts a few centimetres away from the entry point.^¹
• Warmth, swelling, tightness: the skin is warm and tender to the touch, and the leg is often clearly swollen.
• Lymph nodes and lymphatic channels: swollen lymph nodes in the groin or neck, sometimes a red streak running towards the centre of the body.^¹
• Blisters or bleeding into the skin: in complicated forms.

Possible complications

The bacteria can enter the bloodstream and cause blood poisoning (sepsis).^¹,² Rarely, necrotising fasciitis develops, a life-threatening infection that destroys deep tissue layers and the sheaths around muscles.^² A late consequence is more common: every episode of erysipelas damages the lymphatic vessels a little. After repeated episodes, permanent swelling can develop, known as lymphoedema — which in turn makes the next episode more likely.^¹

4. Entry points and risk factors

Streptococci need a small gap in the skin. Whether this turns into erysipelas depends heavily on the condition of the skin and on lymphatic drainage:^¹

• Athlete’s foot between the toes: the classic entry point on the leg. You often do not even notice the fine cracks in the softened skin; more on athlete’s foot.^¹
• Small wounds: scratches, insect bites, torn nail edges, cracked heels, scratched eczema or leg ulcers.^¹
• Lymphoedema: congested, protein-rich lymphatic drainage — for example after lymph node removal for breast cancer — is one of the strongest risk factors, especially for recurrences.^¹
• Venous insufficiency and circulation problems: chronic congestion with varicose veins or an arterial circulation disorder such as peripheral arterial disease (PAD) make healing more difficult.^¹
• Other factors: previous erysipelas, severe obesity, diabetes and a weakened immune system.

5. Diagnosis and ruling out other causes

Erysipelas is a clinical diagnosis: the picture of sharply defined redness and fever is usually clear. The bacteria often cannot be detected in the skin or at the entry point at all.^¹

• Looking at the skin and feet: extent, borders, blisters or bleeding; a targeted search for the entry point, especially between the toes.
• Marking the edge: the border of the redness is often drawn on the skin with a pen so that its course can be assessed over the following days.
• Blood tests: raised inflammatory markers such as CRP and the erythrocyte sedimentation rate, as well as an increased white blood cell count, support the diagnosis.^¹
• Blood cultures: if you have a fever, especially when treatment takes place in hospital.^¹
• Ultrasound: if a deep vein thrombosis in the leg or an abscess is suspected.

Conditions to rule out are mainly:

• a deep vein thrombosis in the leg — a swollen, painful leg, usually without sharply defined redness and without high fever;
• stasis dermatitis due to venous insufficiency or an inflammatory reaction on top of lymphoedema — they look similar to erysipelas but do not need an antibiotic;^¹
• a gout attack, contact eczema, the spreading red rash (erythema migrans) of Lyme disease and, on the face, shingles.

Useful for the appointment: how long you have had a fever, when the redness started, whether you have had erysipelas before, which medicines you take and whether you have had an allergic reaction to penicillin. Tips in our guide Preparing for a doctor’s appointment.

6. Treatment: penicillin, elevation, the entry point

Erysipelas does not reliably heal on its own; it is treated with an antibiotic. Because streptococci in Germany are still sensitive to penicillin, penicillin is the treatment of choice.^¹ Whether tablets are enough or an infusion in hospital is needed depends on the form and on your condition. Your doctor makes this decision.

What else is part of treatment

• Treat the entry point too: according to the guideline, treating the entry point is always part of it, above all athlete’s foot between the toes.^¹ Without this, the risk of recurrence rises.
• Elevate and rest: in the acute phase, it helps to raise the affected leg; this eases swelling and pain. Many people find cool, damp compresses soothing.
• Pain and fever relief: ibuprofen or paracetamol relieve symptoms; which one suits you depends on your stomach, kidneys and your other medicines.
• Thrombosis prevention: if you are bedridden or in hospital, you may be given heparin injections such as enoxaparin, depending on your risk.^⁴
• Treating swelling: once the acute inflammation has subsided, compression therapy is often started if swelling remains — not on your own initiative during the acute infection.

How long? The guideline recommends at least 7 to 10 days, plus one to two days beyond the point at which symptoms have subsided, so that no bacteria survive. With swelling or circulation problems in the legs, it is at least 10 days.^¹ Fever and general well-being usually improve within a few days; the redness takes longer. If things do not improve after two to three days, or get worse, contact your doctor again.

7. Taking antibiotics correctly

• Spread doses evenly: penicillin V is usually taken three times a day, ideally at equal intervals. The package leaflet tells you how it relates to meals.
• Take the full course: even if the fever is gone after two days — what counts is the prescribed duration, not how you feel. More in our guide Taking antibiotics correctly.
• Missed a dose? Do not take a double dose; carry on as described in the package leaflet — see Missed a medicine.
• Clindamycin: take the capsules with a large glass of water. Severe, watery or bloody diarrhoea — even weeks after treatment — can indicate bowel inflammation caused by Clostridioides difficile and must be checked by a doctor immediately.^⁵
• The pill: diarrhoea or vomiting while taking the antibiotic can reduce contraceptive protection — see Medicines and contraception.

Interactions you should know about

Penicillins can delay the excretion of methotrexate and increase its side effects. Clarithromycin inhibits the breakdown of many active substances; it must not be combined with simvastatin because of the risk of severe muscle damage, and caution is also needed with blood thinners and certain heart medicines.^⁵ If you take regular medicines, the complete list belongs with the prescription.

8. Preventing recurrences: long-term penicillin and more

If you have had erysipelas once, you often get it a second time — frequently in the same place. Each episode further damages the lymphatic channels, the swelling increases, and that makes the next recurrence more likely. Breaking this cycle is the real goal after acute treatment.^¹

Long-term prophylaxis is a trade-off: it lowers the risk of recurrence while you take it, but it also affects the gut flora and promotes antibiotic resistance. Whether it makes sense for you is decided by your doctor together with you — depending on how often and how severe the episodes were and how well the risk factors can be addressed.

9. Special cases: face, pregnancy, diabetes

Erysipelas on the face

On the face, erysipelas often starts on the nose or cheek, sometimes from small tears at the entrance to the nostrils. It is considered a complicated form and is usually treated by infusion. Because staphylococci or Haemophilus bacteria can produce a similar picture on the face, the guideline frequently uses cefuroxime here.^¹ Swelling around the eye, vision problems or severe headache are warning signs.

Pregnancy and breastfeeding

Penicillins are among the antibiotics that have long been used during pregnancy and breastfeeding. Erysipelas should therefore be treated consistently in this situation too. Your doctor decides which medicine and which dose are right — background in our guide Medicines during pregnancy.

Diabetes and circulation problems

With diabetes or PAD, wounds heal less well, and an infection on the foot can go deeper more quickly. The guideline provides for a longer treatment duration when circulation problems are present.^¹ Daily foot checks and getting any red, warm area checked by a doctor early are important; more under poor wound healing.

10. Everyday life after erysipelas

• Check your feet every day — especially between the toes. Treat itchy, whitish, softened or cracked skin early.
• Keep your skin supple — moisturise dry lower legs and heels regularly; tips in our guide Applying ointments and creams correctly.
• Wear compression stockings — if they have been prescribed, even after healing. They keep down the swelling that would make the next recurrence more likely. More on water retention.
• Look after injuries — clean and cover small wounds, and wear gloves for gardening, especially on an arm with lymphoedema.
• Hygiene yes, panic no — in everyday life, erysipelas is considered only mildly contagious. Hand washing and your own towels are enough within the family. Anyone who works with food must not work there with infected wounds.^²
• Know the early signs — if you have had erysipelas before, you often recognise chills and beginning redness early. Then see your doctor the same day rather than waiting.

Penicillin to the very last dose — with brite

Reminders for every dose, an interaction check and a medication plan for your next doctor’s appointment. Free.

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