The Australasian College of Dermatologists
Recommendations from the Australasian College of Dermatologists on leg cellulitis, epidermal cysts, urticaria, distorted toenails & acne, advice on systemic non-sedating antihistamines and topical corticosteroids for skin conditions. The Australasian College of Dermatologists (ACD) is the sole medical college accredited by the Australian Medical Council for the training and continuing professional development of medical practitioners in the specialty of dermatology. As the national peak membership organisation, we represent over 550 dermatologist Fellows (FACD) and 100 trainees. We are the leading authority in Australia for dermatology, providing information, advocacy and advice to patients, communities, government and other stakeholders on skin health and dermatological practice.
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.
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.
Supporting evidence
- 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.
- Li DG, Xia FD, Khosravi H, et al. 2018. Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis. JAMA Dermatol. 2018;154(5):537–543.
- Ko LN, Garza-Mayers AC, St John J et al. 2018. Effect of Dermatology Consultation on Outcomes for Patients with Presumed Cellulitis: A Randomized Clinical Trial. JAMA Dermatol. 2018; 154(5):529–536. doi:10.1001/jamadermatol.2017.6196.
- Weng QY, Raff AB, Cohen JM, et al. 2017. Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis. JAMA Dermatol. 2017;153(2):141–146.
- Patel M, Lee SI, Thomas KS, Kai J. 2019. The Red Leg Dilemma: A Scoping Review of the Challenges of Diagnosing Lower-limb Cellulitis. Br J Dermatol. 2019 May;180(5):993-1000.
- Neill BC, Stoecker WV, Hassouneh R et al. 2019. CELLULITIS: A Mnemonic to Increase Accuracy of Cellulitis Diagnosis. Dermatol Online J. 2019 Jan 15;25(1). pii. 13030/qt9mt4b2kc.
How this list was made
College’s Expert Advisory Committee, comprising seven longstanding Fellows considered four potential recommendations, together with supporting evidence, and agreed to proceed with three of them. The Committee then refined and finalised the recommendations. These were reviewed by the NPS Representatives Committee and finalised in response to the feedback received.
- 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.
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3
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.
- 6 Do not recommend that patients take systemic non-sedating antihistamine for itchy rashes, i.e. eczema, psoriasis. Non-sedating antihistamines can be prescribed for urticaria according to the ASCIA guidelines.
- 7 Do not routinely prescribe or recommend topical steroids Class II and above on the face including periorbital areas, or flexural areas of skin (axilla/groin and natal cleft).
- 8 Review your diagnosis and/or treatment/adherence if patient has not responded to adequate prescribed topical steroids after two weeks.