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Skin and Soft Tissue Infections

M. Lee Chambliss, MD, MSPH
Alison Rumball, DO
Carina M. Brown, MD

American Family Physician. 2026;113(5):440-448.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Skin and soft tissue infections range from mild bacterial infections of the dermis and lymphatic system, such as erysipelas, to rapidly spreading necrotizing fasciitis. Mild infections are often caused by methicillin-sensitive Staphylococcus aureus and Streptococcus species, whereas more severe infections are often polymicrobial and involve anaerobic bacteria. Purulent skin infections are more likely to be caused by methicillin-resistant S aureus (MRSA). Nasal polymerase chain reaction testing for MRSA may be helpful for skin infections associated with a wound, but it cannot rule out MRSA as the cause of simple cellulitis or abscess. Before diagnosing cellulitis, clinicians should consider other possible causes such as venous stasis dermatitis and deep venous thrombosis. Bilateral cellulitis is rare. Cellulitis is a clinical diagnosis, but white blood cell count can indicate severity. Nonpurulent, mild cellulitis should be treated with penicillin or first-generation cephalosporins for 5 days. For nonpurulent, severe infections, antibiotic therapy that covers MRSA and anaerobic bacteria is warranted. Point-of-care ultrasonography can reliably differentiate cellulitis from abscess. Abscesses should be treated with incision and drainage, followed by antibiotics such as clindamycin or trimethoprim/sulfamethoxazole to reduce the risk of treatment failure. Recurrence of cellulitis is common, occurring in as many as 29% of cases. Risk factors for recurrence include lymphedema, dependent lower extremity edema, and malignancy.

Skin and soft tissue infections are often seen in the outpatient and inpatient settings, with increased incidence in summer months. Abscesses and cellulitis account for approximately 60% of infections, and most are treated in the ambulatory setting.1 Although retrospective data differ regarding the incidence of skin and soft tissue infections, the incidence is higher than other infections such as pneumonia and urinary tract infection.1–3

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
For patients presenting with bilateral lower extremity erythema and warmth, physicians should consider other noninfectious causes of symptoms such as venous stasis dermatitis, because bilateral cellulitis is rare.8 C Case series and consensus opinion
Point-of-care ultrasonography can reliably distinguish abscess from cellulitis.29 B Meta-analysis of prospective and randomized trials
For uncomplicated abscesses, the addition of antibiotics after incision and drainage reduces the risk of treatment failure and recurrence with increased gastrointestinal adverse effects.38 B Meta-analysis of randomized trials and expert guidelines
Five days of antibiotics for uncomplicated cellulitis are as effective as longer courses.10 C Consensus guidelines
For patients with two or more episodes of lower extremity cellulitis of the same area in the past 24 months, compression stockings are recommended to reduce the risk of recurrence.51 B Single randomized trial (number needed to treat = 4)

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Skin and soft tissue infections, including cellulitis, are commonly caused by gram-positive pathogens such as Staphylococcus aureus and Streptococcus species. Methicillin-resistant S aureus (MRSA) and anaerobic species can also cause skin and soft tissue infections, particularly purulent infections in those with underlying risk factors or severe infection.3 The proportion of skin and soft tissue infections caused by MRSA has been increasing over the past 2 decades, although health care–associated MRSA appears to be declining.2,4,5

M. LEE CHAMBLISS, MD, MSPH, is a professor in the Cone Health Family Medicine Residency Program affiliated with University of North Carolina-Chapel Hill Family Medicine, Greensboro.

ALISON RUMBALL, DO, is an assistant professor in the Cone Health Family Medicine Residency Program affiliated with UNC-Chapel Hill Family Medicine, Greensboro.

CARINA M. BROWN, MD, is an associate professor in the Cone Health Family Medicine Residency Program affiliated with UNC-Chapel Hill Family Medicine, Greensboro.

Address correspondence to M. Lee Chambliss, MD, MSPH, at lee.chambliss@conehealth.com.

Author disclosure: No relevant financial relationships.

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