The red leg dilemma: a scoping review of the challenges of diagnosing lower limb cellulitis

Background: Suspected lower limb cellulitis presentations are commonly misdiagnoses, resulting in avoidable antibiotic prescribing or hospital admissions. Understanding the challenges posed in diagnosing cellulitis may help enhance future care.Objectives: To examine and map out the challenges and facilitators identified by patients and health professionals in diagnosing lower limb cellulitis.Methods: A scoping systematic review was performed in MEDLINE and Embase in October 2017. Thematic analysis was used to identify key themes. Quantitative data was summarised by narrative synthesis.Results: Three themes were explored: (i) clinical case reports of misdiagnosis, (ii) service development and (iii) diagnostic aids. Forty‐seven different pathologies were misdiagnosed, including seven malignancies. Two different services have been piloted to reduce the misdiagnosis rates of lower limb cellulitis and save costs. Four studies have looked at biochemical markers, imaging and a scoring tool to aid diagnosis.Conclusions: This review highlights the range of alternative pathologies that can be misdiagnosed as cellulitis, and emerging services and diagnostic aids developed to minimise misdiagnosis. Future work should focus on gaining a greater qualitative understanding of the diagnostic challenges from the perspective of patients and clinicians.This article is protected by copyright. All rights reserved

Skin Ulcer: A Long-Term Complication After Massive Liquid Silicone Oil Infiltration

Despite scientific literature replete with stories of disastrous results and disfigurement, illicit subcutaneous injections of highly viscous fluids in massive quantities still are performed, often by unqualified persons. The authors present a devastating long-term outcome from a massive volume of silicone oil injected subcutaneously into the buttocks of a 48-year-old transsexual patient and its ulceration treated only through regular medications. The therapeutic protocol consisted of wound disinfection with iodopovidone, washing with saline solution, disinfection with sodium hypochlorite 0.05 %, and application of ointment containing Vibrio alginolyticus collagenase and hyaluronan. The follow-up evaluation was at 1 and 2 weeks and then at 1, 2, and 3 months. Weekly photographs were taken, and measurements of the lesion and evolution were estimated every 7 days. After 3 months of regular medications, the authors succeeded in closing the ulcer, avoiding invasive therapeutic options. In the presence of the cutaneous ulceration above a massively infiltrated area, if the removal of all the injected oil is surgically definitely impossible, other conservative procedures should be considered. Our experience demonstrated how it is possible to manage a so prickly a case with a noninvasive approach such as periodic medications. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

Inflammatory Nodules Following Soft Tissue Filler Use: A Review of Causative Agents, Pathology and Treatment Options

Nodule development is a common complication following the use of fillers for soft tissue augmentation and is commonly categorized as inflammatory or non-inflammatory in nature. Inflammatory nodules may appear anywhere from days to years after treatment, whereas non-inflammatory nodules are typically seen immediately following implantation and are usually secondary to improper placement of the filler. Although inflammatory nodules are more common with permanent fillers such as silicone, inflammatory nodule development following administration of temporary fillers such as hyaluronic acid and collagen has also been reported. Treated many times with corticosteroids due to their anti-inflammatory properties, inflammatory nodules may be secondary to infection or biofilm formation, warranting the use of alternative agents. Appropriate and prompt diagnosis is important in avoiding delay of treatment or long-term complications for the patient. This paper addresses the etiology, development, and studied treatment options available for inflammatory nodules secondary to each of the major classes of fillers. With this knowledge, practitioners may expeditiously recognize and manage this common side effect and thus maximize functional and aesthetic benefit