From Pages to Practice

By Jehan F. Chowdhury, DO

Published September 16, 2020


Maria is a 56-year-old woman with a history of obesity, lymphedema, and recurrent cellulitis. She has had three episodes of cellulitis in the left leg in the past year. She asks about therapies to prevent recurrences and the need for repeated courses of antibiotics.

Cellulitis is a common bacterial infection of the skin and subcutaneous tissue, and chronic edema of the legs is a known risk factor for recurrence. Up to 47% of patients with cellulitis experience a recurrence within 3 years. Antimicrobial therapy is used to treat cellulitis and sometimes penicillin is used as chronic prophylaxis to prevent recurrences. However, chronic antibiotic use is associated with adverse effects, including antimicrobial resistance and Clostridium difficile diarrhea. Compression therapy, involving the use of daily compression garments such as stockings, has been recommended for prevention of recurrent cellulitis, but few trials have assessed its effectiveness.

In a single-center, nonblinded, randomized-controlled trial conducted in Australia, investigators examined the effectiveness of compression therapy in preventing the recurrence of cellulitis in patients with chronic leg edema. Participants received either compression therapy plus education on how to prevent cellulitis or education alone (control group) and were followed-up every 6 months for a maximum of 3 years. If patients in the control group had an episode of cellulitis, they were crossed over to the compression-therapy group. The primary outcome was the recurrence of cellulitis.

In an interim analysis of 84 patients, 6 participants (15%) in the compression group and 17 (40%) in the control group had an episode of cellulitis (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.59; P=0.002; relative risk [post hoc analysis], 0.37; 95% CI, 0.16 to 0.84; P = 0.02). The trial was stopped early for efficacy. No adverse events were reported during the trial.

The results of this small, single-center trial suggest that compression therapy lowers the incidence of recurrent cellulitis. However, the unblinded design could have introduced bias in that the practitioners who made the diagnosis of cellulitis could have been influenced by the patients who were aware of their treatment assignment. Further, the trial assessors requested early review of trial results because of anecdotally reported outcomes that favored the compression-therapy group. Despite these caveats, the results suggest that Maria could benefit from the use of compression stockings to prevent recurrence of cellulitis.

The following NEJM Journal Watch summary further explains the study.


Compression Therapy to Prevent Recurrent Leg Cellulitis

Allan S. Brett, MD reviewing Webb E et al. N Engl J Med 2020 Aug 13

Does compression therapy prevent recurrent cellulitis in patients with chronic leg edema? To find out, researchers in Australia conducted this single-center randomized trial that involved patients with chronic leg edema and at least two episodes of leg cellulitis in the past 2 years. Mean age was 64; common underlying conditions included obesity, history of surgery or trauma, chronic venous insufficiency, and heart failure.

Patients were randomized to knee-high compression stockings (fitted by specialized lymphedema physiotherapists) or to a control group; both groups received general education on preventing cellulitis. The study was stopped by a data monitoring committee after 84 patients had been randomized. At that point (median follow-up, 6 months), an episode of cellulitis had been diagnosed in significantly fewer compression-therapy patients than controls (15% vs. 40%; P=0.02).

Comment: This study shows that compression therapy can lower the incidence of recurrent cellulitis in patients with chronic edema. However, the study was conducted in a single center, specialized therapists provided the intervention and monitored patients, and physicians who diagnosed cellulitis were aware of the group to which patients were assigned (a source of potential bias). The results make sense, but whether they can be duplicated widely is unclear.

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Jehan is a 2020-2021 NEJM Editorial Fellow and an Infectious Disease physician. She completed her Infectious Disease fellowship at Tufts Medical Center.