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A practical guide to the diagnosis and treatment of red legs by Linda Nazarko

Linda NazarkoLinda Nazarko

Linda Nazarko OBE Consultant Nurse Older People London North West Healthcare NHS Trust speaking at todays Prescribing event and will discuss the importance of correct diagnosis using a case study: cellulitis? diagnosis and treatment of red legs: this session provides a practical guide to the diagnosis and treatment of red legs: 

  • cellulitis is misdiagnosed in 28-33 percent of cases. Examining the clinical features of  common causes of red legs using differential diagnosis
  • lipodermatosclerosis Venous Eczema Cellulitis
  • working out differential diagnosis and treatment options in clinical practice
  • the importance of diagnosis


The NHS utilises 400,000 bed days and spends - £254 million annually on the admission and treatment of people with lower leg cellulitis one third of this inappropriately. Every year 132,000 bed days and £84.5 million pounds are wasted because of misdiagnosis (Nazarko, 2012a, Nazarko, 2012b). 

The number of people admitted to hospital for treatment of lower leg cellulitis increased by 77% from 2004 to 2011 (NHS Information Centre, 2011). Despite the increase in outpatient antibiotic therapy (OPAT) services, the NHS now spends between £172–£254 million a year on inpatient treatment of people with lower leg cellulitis (Curtis, 2011). However, one-third of those diagnosed are misdiagnosed (Levell et al, 2011).

Misdiagnosis exposes patients to the hazards of inappropriate antibiotic therapy, causes treatment delays and is costly. This presentation aims to enable prescribers to use an evidence based approach to diagnose and treat cellulitis and other causes of “red legs”.

Cellulitis is frequently confused with other conditions that lead to red legs including venous eczema, acute lipodermatosclerosis and chronic lipodermatosclerosis. All of these conditions are associated with ageing, immobility and obesity.

Adopting a systematic approach enables the prescriber to provide the patient with an accurate diagnosis, appropriate treatment and advice on management and aftercare. 

This enables the nurse to provide care that avoids the hazards of inappropriate antibiotic prescribing and inappropriate treatment and promotes health and well being. 

Unresponsive/unusual organisms

When cellulitis fails to respond to standard treatment there are a number of possible reasons. These include wrong diagnosis, wrong antibiotic or patient factors preventing appropriate response.

If in doubt the nurse should head the advice of medical colleagues such as Dr Lasanga (1964)

“I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery”.

Conditions which may be misdiagnosed as cellulitis include Sweet’s syndrome and Sweet’s syndrome, also known as acute febrile neutrophilic dermatoses, is a condition that was originally described by Dr. Robert Sweet in 1964. It has four features: fever; leukocytosis; acute, tender, red plaques; and a papillary dermal infiltrate of neutrophils. Two of these features must be present to confirm diagnosis.  The cause is unknown but it may be indicative of an underlying disease process. Treatment is normally with intravenous corticosteroids however other treatments include potassium iodide and colchicine and indomethacin, clofazimine, cyclosporine (ciclosporin), and dapsone (Cohen, 2009)

Occasionally, cellulitis may be caused by the spread of subjacent osteomyelitis. Pneumococcal cellulitis can occur in patients with diabetes mellitus, alcohol abuse, systemic lupus erythematosus, nephrotic syndrome, or a haematological cancer (Prada and Maslow, 2002). Meningococcal cellulitis is rare (Porras, 2001).

Cellulitis caused by other gram-negative organisms (e.g., E. coli) usually enters through a wound in an immunocompromised patient but can also develop through bacteraemia (Gach et al, 2002).

Cellulitis can also be caused by B streptococci (e.g., Streptococcus agalactiae) this is more common in older people. Pseudomonas aeruginosa is more common in those with diabetes and older people. Animal bites can lead to Pasteurella multocida (cat bite) Capnocytophaga sp (dog bite).  Immersion injuries in fresh water may result in cellulitis caused by Aeromonas hydrophila; in warm salt water, by Vibrio vulnificus (Stanway, 2011).

When a patient is not responding to standard treatment it is important to seek expert advice from microbiology and dermatology in order to ensure that diagnosis is correct and appropriate therapy is being prescribed.

The nurse clinician can with a little education and support from more experienced colleagues gain the skills to accurately diagnose the various causes of red legs and work with the patient to resolve symptoms and reduce the risks of recurrence.  Skilled educated nurses can and do make a huge difference to the quality of care a patient receives. 

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Linda Nazarko, MSc, PgDip, Pg Cert, BSc (Hons), RN, NIP, OBE, FRCN is consultant nurse at London North West Healthcare NHS Trust.  She works as a clinician, educator and adviser with colleagues in the inpatient units and within intermediate care and community teams. Linda has clinical responsibility for two nurse led inpatient wards in a community hospital.  She leads a team of nurses and therapists and admits patients directly from home and from A&E into the step up unit and from acute hospitals into the step down unit.  Linda is also clinical lead for the IV service. She has for the last year led on improving care for people with dementia within Intermediate Care Ealing.

Linda lectures and assesses at universities and speaks at conferences in the UK and Europe. 

Linda’s has specialised in care of older people for 30 years and has qualifications in gerontology, nurse prescribing, continence, stoma care, and management.

She is the author of several books reviews and contributes to major UK nursing journals.

Events of interest:

Delivering 7 day services in Hospital Pharmacy
Tuesday 13 January 2015 London

Reducing Medication Errors
Tuesday 27 January 2015 London

Advancing IV Therapy
Thursday 29 January 2015 London

Electronic Prescribing In Hospitals: Moving Forward
Wednesday 22 April 2015 London

Download: Linda Nazarko's Presentation

5 December 2014


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