Para/Medic: Understanding Cellulitis

Bob VogelQ. I’m 49 and in my 24th year as a T9 complete para. Over the last eight years I’ve been hospitalized three times with cellulitis in my right leg. The first two times I noticed it during my daily “mirror skin check”— a bright red area, warm to the touch, like a bad rash. The first time it started around a small burn on my foot.  The second one started where I had clipped a toenail too short and it bled.

In both instances the red area was spreading outward and getting larger by the hour, so I went to the emergency room. Each time I was admitted to the hospital and put on IV antibiotics. Within a few days of treatment the skin returned to its normal color, and I was released and put on a course of oral antibiotics.
In my latest bout my foot was slightly swollen, and I had a small area of warm, red skin near a tiny crack of athlete’s foot by my little toe. Within hours I developed intense shivers, my entire body hurt, I spiked a fever of 104 and was puking. I thought I had a major urinary tract infection and headed to the ER.

The ER doc looked at my lower leg, now red, hot and swollen, and said, “cellulitis.” He admitted me to the hospital, where I got an IV PICC line. It took seven days of heavy antibiotics before I felt better and the swelling went down.

This last time really knocked the stuffing out of me. Does SCI make me more susceptible to cellulitis? What can I do to avoid it?
— Tom

A. Tom, although an Internet search of studies on cellulitis and SCI came up pretty thin, it seems to be a common pitfall among wheelers — I’ve had a few battles with it myself.

Cellulitis is a common and potentially serious bacterial skin infection that can rapidly spread throughout the body. It occurs when one or more types of bacteria enter the body through a break in the skin — a scratch, burn, insect bite, cracked dry skin, athlete’s foot, pressure sore, ingrown toenail, etc. It most commonly affects the lower legs, but can occur anywhere on the body.

Early diagnosis of cellulitis is critical — when it can be treated with a course of oral antibiotics. Left untreated, it can rapidly spread to tissues under the skin, the lymph nodes and bloodstream. Advanced infections may require a hospital stay and IV antibiotics. Serious infections can lead to sepsis or amputation, and can even be fatal!

Visual symptoms include an area of skin that is red or reddish/orange and warm to the touch. The area may be raised or swollen — some people describe the swollen area as having a “doughy” feel to it. These symptoms warrant a trip to the doctor the same day.

Symptoms of an advanced cellulitis infection include a rapidly expanding area of red skin — noticeable over several hours — or red streaks extending out from the infection, or an area of red skin accompanied by high fever, chills or nausea. These symptoms should be evaluated at urgent care or an ER right away.

“Because cellulitis manifests with pain and itching, nondisabled people catch it quickly,” says Dr. Carolyn Tillquist, an infectious disease physician at Craig and Swedish hospitals in the Denver area. “With compromised sensation, it is easier for the disease to spread in people with SCI.” This is another reason that daily skin checks are important — it’s best to catch it in its early stages.

People with SCI report that often their first symptoms of cellulitis are a general rundown feeling, identical to the onset of a UTI. The area of red, swollen skin soon follows.

Tillquist says although she hasn’t come across any studies showing people with SCI have higher rates of cellulitis, it seems logical. “When you have compromised blood flow, you are more susceptible to cellulitis,” she says. “Edema makes you even more susceptible. People with diabetes are more prone to cellulitis, because they have compromised blood flow in their legs and also limited sensation … similar to somebody with SCI.”

According to Tillquist, SCI seems to make the arms susceptible as well. “I’ve seen cases where bursitis in the elbow (inflammation of the bursa — the sac that lubricates a joint) causes irritation that leads to cellulitis. It is important for a physician to distinguish cellulitis from bursitis.” Tillquist has also seen quads develop cellulitis in their arms from pressure points on their armrests that compromise tissue.

She says the visual symptoms of cellulitis are similar to those of a blood clot. Because of this, the usual practice is to do a Doppler ultrasound to rule this out.

There are steps that can help reduce the odds of getting cellulitis. Tillquist says if you have edema, asking your physician about ways to control it should be number one on your list. Wearing compression stockings during the day helps in controlling edema. However, it is important to have a physician or therapist prescribe the correct type and get a proper fit. Reputable medical supply stores can help with fit. Another way to help control edema is to elevate your legs during the day — whenever you have a chance — and sleep with your lower legs elevated by pillows at night.

Carefully wash and dry your legs and feet each day, paying extra attention to drying between the toes. Keep an eye out for athlete’s foot and use an antifungal cream if it crops up. Use care when trimming toenails so you don’t nick the skin.

Wear properly fitting shoes that don’t create red “hot spots” on your feet. Wear clothing that covers areas prone to cuts and scrapes. Consider wearing neoprene “fin socks” (about $5-$10) and neoprene knee pads (about $15) to protect your knees and feet from scrapes while swimming in a pool, lake or river.

Do daily skin checks with a mirror. Moisturize areas of dry skin to prevent cracking. Gently wash any break in the skin with soap and water and cover it with a dressing or bandage until a scab forms.

Another way to help reduce edema and keep cellulitis at bay is getting regular aerobic exercise, if possible. Friends of mine who have become handcycle fanatics report that, besides feeling more fit, exercise has reduced edema in their legs, and they haven’t had a bout of cellulitis since starting to ride regularly.

Although these steps may sound like a lot to do, they only take a few extra minutes a day — well worth it to avoid antibiotics and hospital food.

Advice in this column is supported by Craig Hospital’s SCI Nurse Advice Line, a toll-free hotline for people living with SCI, a community service partially funded by grants from the PVA Education Foundation, Craig H. Nielsen Foundation, and Caring for Colorado Foundation. For non-emergency nursing information about SCI health, call 800/247-0257 between 9 a.m. and 4 p.m. Mountain Time. If you have a health question, contact Bob Vogel at rhvshark@mac.com.

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