Your Good Health: Cellulitis persists, despite variety of treatments

Dear Dr. Roach: I am having a serious, lengthy battle with cellulitis on my lower leg. For nearly three months, nothing any doctor has recommended or prescribed has worked. The inflammation and skin discolouration have not abated even with three days of intravenous injections of antibiotics and three courses of antibiotic pills. I have soaked my leg in Epsom salt, used antibiotic creams, Vicks rub, aspirin for inflammation, raised my leg when I am sitting — all to no avail. The doctors I have seen seem to have thrown up their hands and offer no resolution. Every medical person who sees my leg immediately diagnoses the problem to be cellulitis. An ultrasound showed no blood clot.

This occurred after a 15-hour plane flight and a subsequent day of walking — about 18,000 steps. I wore support hose on the flight and moved as much as possible. I basically missed a night of sleep, walked for several hours, went to bed and was woken in the night with leg cramps and the swelling and rash. There was no break in the skin nor insect bite that I was aware of. I am female, 75, in fairly good health, not obese, do not have any circulation problems.

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I know that an infection lasting so long is very dangerous and can lead to sepsis. I am willing to do whatever is necessary to rid myself of this bacterial menace. Please advise, and soon, as I am desperate!

T.E.

Cellulitis, infection of the deeper tissues of the skin, is a common infection. It is usually caused by Staphylococcal or Streptococcal bacteria. Not everything that looks like cellulitis is an infection, however, and when several courses of antibiotics have failed, it’s time to reconsider the diagnosis.

Looking for a blood clot was wise; blood clots can cause redness and swelling that looks very much like cellulitis sometimes. A deep-tissue abscess can prevent cure with antibiotics, but that should be apparent after a few days, let alone three months.

There are several other less-common chronic skin conditions that can mimic cellulitis.

A wound-care nurse colleague of mine with far more experience than me suggested the possibility of acute lipodermatosclerosis, which is a noninfectious inflammation of the deep skin. It happens more commonly in people with poor venous drainage of the legs, which is common in women (but men, too) in middle age. The airplane flight and walking is a setup for exacerbating any venous insufficiency. This condition is diagnosed by a wound care expert or dermatologist, and is usually treated by high-potency steroid creams and compression. It can frequently be misdiagnosed in its early stages, and is among the most common skin disorders misdiagnosed as cellulitis.

Dear Dr Roach: I’m 53 and perimenopausal. I’ve been very emotional. I don’t want to cry about every little thing — it’s embarrassing! What do you suggest?

T.

Mood lability (ups and downs) are very common in women in early menopause. Mood symptoms are effectively treated with hormone replacement, but not everyone needs it. However, particularly for women with depression, hormone therapy can be very effective when combined with an antidepressant. I do not recommend medication treatment lightly, but depression is a condition I take very seriously. Since the incidence of depression is high during the time of menopause, I discuss the risks and benefits of hormonal therapy (sometimes along with antidepressant medication).

Many women are able to taper off treatment in a year. The risks of hormone treatment for a year are small, but still need to be discussed.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers can email questions to ToYourGoodHealth@med.cornell.edu

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