Treatment of Facial Cellulitis

Classification and Diagnosis

Facial cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue presenting with local signs of inflammation including warmth, erythema, pain, and swelling 2, 1
Periorbital cellulitis specifically involves only the eyelid, while postseptal inflammation involves structures of the orbit 1
Diagnosis is primarily clinical, based on physical examination findings of erythema, swelling, and tenderness 1
Blood cultures are not routinely recommended for typical cases but should be considered in immunocompromised patients or those with systemic symptoms 2, 1

High-dose amoxicillin-clavulanate is recommended as first-line therapy for comprehensive coverage of both streptococci and staphylococci 1
For penicillin-allergic patients, clindamycin is an effective alternative that covers both streptococci and community-acquired MRSA 3, 1
Treatment duration is typically 5 days, extending if no improvement is seen 2, 1
For nonpurulent facial cellulitis, empirical therapy for β-hemolytic streptococci is recommended 3
For purulent facial cellulitis, empirical coverage for CA-MRSA should be considered pending culture results 3

High-dose amoxicillin-clavulanate (first-line) 1
Clindamycin (covers both streptococci and CA-MRSA) 3, 1
Vancomycin (for MRSA coverage) 3, 1
Vancomycin plus piperacillin-tazobactam or imipenem/meropenem for severe infections 1

Periorbital cellulitis requires prompt treatment due to risk of orbital involvement and potential vision loss 1
Daily assessment until definite improvement is noted is recommended 1
Monitor for signs of orbital involvement (proptosis, ophthalmoplegia, pain with eye movement, vision changes) 1

Elevation of the affected area to promote gravity drainage of edema and inflammatory substances 2, 1
Treatment of predisposing factors such as underlying skin conditions 2
Consider systemic corticosteroids in non-diabetic adult patients with severe inflammation 2

Search for and address local causes such as chronic skin conditions 2
Treat predisposing conditions such as edema, eczema, or other skin disorders 2
For recurrent S. aureus infections, consider a 5-day decolonization regimen including intranasal mupirocin and daily chlorhexidine washes 2
Consider prophylactic antibiotics in patients with 3-4 episodes per year despite treatment of predisposing factors 2

Failure to recognize progression from periorbital to orbital cellulitis can lead to permanent blindness if not treated promptly 1
Inadequate antibiotic coverage for both streptococci and staphylococci can lead to treatment failure 1
Not obtaining imaging when signs of orbital involvement are present can delay diagnosis and treatment 1
The use of rifampin as a single agent or as adjunctive therapy for the treatment of skin and soft tissue infections is not recommended 3