A 40-year-old man comes to the physician with pain, swelling, warmth, and redness of his distal right lower extremity for the past 3 days. No recent trauma has occurred to the area. He had a similar episode 1 year ago in his right leg and was hospitalized for cellulitis, which responded quickly to antibiotics. He has no previous history of lower-extremity edema or recurrent infections. The patient exercises at a gym 3 times a week. He does not use tobacco or illicit drugs and works as an accountant.
Vital signs are within normal limits. BMI is 32 kg/m². Examination shows swelling, warmth, and erythema of his right lower extremity starting from his foot up to the mid-calf region. There is also erythema in the 1st and 2nd toe web spaces with chronic-appearing skin erosions. There is no purulent drainage or ulcers. Pulses are 2+ in the bilateral lower extremities.
In addition to treatment of his cellulitis, which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_985f_df28_853d_2714605704e3_MD0002_00 Recurrent cellulitis can occur in up to 30% of patients after an initial episode and is usually due to lymphatic stasis or skin barrier breakdown. This patient's erythema in the toe web spaces is most consistent with tinea pedis. Tinea pedis can cause skin breakdown between the toes and is a potential site for bacterial entry in this small area often overlooked by clinicians. The bacteria can then spread to adjacent tissues to cause cellulitis. As a result, treating this patient's underlying tinea pedis may decrease future episodes of ipsilateral cellulitis. (Choices A and B) Limited studies suggest that prophylactic antibiotics may reduce recurrent cellulitis in patients with > 2 episodes over a 6-month period or with untreatable predisposing factors (eg, abnormal anatomy due to lymph node dissection, large hemangioma, or congenital malformations). (Choice C) Skin biopsy would be indicated if the cellulitis does not respond to usual antibiotic therapy. (Choice E) Obesity may be associated with recurrent cellulitis due to increased hydrostatic pressure from lower-extremity venous stasis or lymphatic stasis. However, this patient should first be treated for his obvious tinea infection that is causing recurrent cellulitis in the same leg. Educational objective: Recurrent cellulitis can occur in up to 30% of patients after an initial episode and is usually due to lymphatic stasis or skin barrier breakdown. Tinea pedis can cause skin breakdown between the toes and is a potential site for bacterial entry in this small area often overlooked by clinicians. Treatment of underlying tinea pedis can decrease the incidence of recurrent episodes of ipsilateral cellulitis. __________ References: Lower limb cellulitis and its mimics: part I. lower limb cellulitis. (http://www.ncbi.nlm.nih.gov/pubmed/22794815) Association of athlete's foot with cellulitis of the lower extremities: diagnostic value of bacterial cultures of ipsilateral interdigital space samples. (http://www.ncbi.nlm.nih.gov/pubmed/8922818)

A 40-Year-Old Man Comes to the Physician with Pain, Swelling