normal  medium  large

CELLULITIS OF THE HAND

Introduction

Cellulitis is a bacterial infection of the skin and subcutaneous tissues. The most common bacteria involved include Staphylococcus and Streptococcus. In recent years, community-acquired methicillin-resistant Staphylococcus aureus (ca-MRSA) has become a more prevalent cause. Cellulitis needs to be treated in a timely manner, especially for high-risk patients, to prevent abscess formation, which may spread the infection to other parts of the body.

Related Anatomy

  • Skin
  • Subcutaneous tissue

Incidence and Related Conditions

  • ca-MRSA infections have become more common since 2008

Differential Diagnosis

  • Herpetic whitlow
  • Paronychia
  • Felon finger
  • Necrotizing fasciitis
Clinical Presentation Photos and Related Diagrams
  • Cellulitis Left Index Finger (Hover over right edge to see more images)
    Cellulitis Left Index Finger (Hover over right edge to see more images)
  • Cellulitis Left Volar Wrist with abcess
    Cellulitis Left Volar Wrist with abcess
  • Cellulitis right hand stating to resolve after I & D of associated abcess
    Cellulitis right hand starting to resolve after I & D of associated abcess
Symptoms
• Tenderness and red areas in the skin
• Sometimes involves breaks in the skin, due to a splinter, insect bite or small cut
• MRSA can produce skin breaks with a spider-bite appearance
Typical History

The patient usually presents with swelling and redness of the hand. Farmers, scuba divers and people who work with animals are susceptible to cellulitis. Children, especially those who play contact sports, may be at higher risk for MRSA infections of the hand. Extra care should be taken with patients who have diabetes, immune deficiencies or abuse intravenous drugs.

Positive Tests, Exams or Signs
Tenderness
Work-up Options
Magnetic resonance imaging - MRI without contrast
Laboratory tests - blood tests
Radiology studies - X-ray
Images (X-Ray, MRI, etc.)
  • Cellulitis secondary to cat bite. Note soft tissue swelling (arrows). Bones are normal.
    Cellulitis secondary to cat bite. Note soft tissue swelling (arrows). Bones are normal.
Treatment Options
Conservative: 
  • Rest the affected areas
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Oral antibiotics: trimethoprim-sulfamethoxazole can be used for MRSA infections
  • Intravenous (IV) antibiotics: use vancomycin or clindamycin if hospitalized
    • Clindamycin should be avoided if patient history includes drug use
Operative: 
  • In rare cases for MRSA infections, use surgical debridement to excise the infected tissue
Complications
  • Abcscess, bacteremia and septicemia
Outcomes
  • Results are usually positive if the cellulitis is treated quickly with appropriate antibiotics
Key Educational Points
  • It is possible to be a carrier of ca-MRSA, but not to show any symptoms.
  • Povidone-iodine soaks are not useful after operative treatment.
  • If left untreated, cellulitis may lead to necrotizing fasciitis.
Practice and CME
References

New Articles

  1. Tosti R, Iorio J, Fowler JR. Povidone-Iodine Soaks for Hand Abscesses: A Prospective Randomized Trial. J Hand Surg Am 2014;39(5):962-5. PMID: 24636027
  2. Tosti R, Trionfo A, Gaughan J, Iyas AM. Risk Factors Associated With Clindamycin-Resistant, Methicillin-Resistant Staphylococcus aureus in Hand Abscesses.  J Hand Surg Am 2015;40(4):673-6. PMID: 25707549

Reviews

  1. Osterman M, Draeger R, Stern P. Acute Hand Infections.  J Hand Surg Am 2014;39(8):1628-35. PMID: 25070032
  2. Ritting AW, O'Malley MP, Rodner CM. Acute Paronychia. J Hand Surg Am 2012;37(5):1068-70. PMID: 22305431

Classics

  1. Florey, W. Hand infections treated with penicillin. Lancet 1944;1:73-81.