Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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Acute cellulitis or sepsis
New painful warmth, erythema and swelling with fever, rigors, confusion, hypotension or rapidly worsening local signs is an acute infection, not prophylaxis failure alone.
Action: Assess severity and sepsis risk immediately, start the appropriate acute-treatment pathway, and arrange hospital care for physiological compromise, severe systemic illness or threatening local progression.
Synopsis
Reduce recurrent cellulitis in lymphoedema through oedema control, skin and portal care, accurate episode counting and appropriately governed antibiotic prophylaxis.
An acute attack needs prompt assessment and a full acute-treatment course; do not continue prophylactic-dose antibiotic as though it treats active cellulitis, and stop prophylaxis while acute antibiotics are taken.
Control swelling with specialist lymphoedema therapy and compression when tolerated, because compression and decongestive care reduce recurrence; remove a garment during an attack if it is painful and reintroduce it as inflammation settles.
Treat portals and mimics: daily emollient skin care, wounds, dermatitis, lymphorrhoea, interdigital maceration and fungal infection; repeated venous inflammation or incompletely treated cellulitis should not be miscounted as new attacks.
Key red flags
Hypotension, confusion, tachypnoea, hypoxia, rigors or rapidly progressive inflammation indicates possible sepsis and needs urgent hospital assessment.
Pain out of proportion, skin anaesthesia, bullae, dusky discoloration or crepitus raises concern for necrotising infection and requires emergency surgical assessment.
New whole-limb swelling, deep tenderness, chest pain or breathlessness may represent DVT or PE rather than uncomplicated recurrent cellulitis.
Failure to improve or worsening systemic or local signs within 48 hours requires reassessment of diagnosis, adherence, antimicrobial choice and need for admission.
Investigation priorities
01
Clinical episode recordFirst step
Verify the number, timing, severity and treatment of separate bacterial cellulitis attacks before prophylaxis is considered.
Management branches
Prevention pathwayAfter recovery from cellulitis
Use once acute infection has been adequately treated and the patient can resume lymphoedema self-management.
Confirm that erythema, systemic illness and tenderness are resolving, reintroduce well-fitting compression when comfortable, and restore movement and oedema-control routines.
Inspect and treat toe-web fungus, fissures, dermatitis, wounds, ulcers and lymphorrhoea; teach daily washing, careful drying, bland emollient use and prompt protection of skin injury.
Use for two or more credible attacks in a year when BLS lymphoedema-specific guidance governs, after risk factors and mimics have been reviewed.
Key medicines
Phenoxymethylpenicillin for BLS lymphoedema prophylaxisTake 250 mg orally every 12 hours; use 500 mg every 12 hours if BMI is at least 33. Review after one successful year for stopping or extension.Confirm the nature of any penicillin allergy. Balance resistance and long-term adverse effects; stop during acute-treatment antibiotics. Continue another year only for persistent risks and review lifelong use at least annually.
Doxycycline for BLS penicillin-allergy prophylaxisTake 100 mg orally once daily while specialist prophylaxis remains indicated; reassess at one year and at least annually if continued long term.The BLS/LSN regimen is not used in pregnancy; its pregnancy alternative is erythromycin 250 mg every 12 hours. Confirm the allergy history and review continued need rather than prescribing indefinitely.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 13 Sept 2026; clinical approval remains outstanding.