The Red Leg Dilemma: A Scoping Review of the Challenges of Diagnosing Lower-limb Cellulitis

M. Patel; S.I. Lee; K.S. Thomas; J. Kai


The British Journal of Dermatology. 2019;180(5):993-1000. 

In This Article

Abstract and Introduction


Background: Presentations of suspected lower-limb cellulitis 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 were summarized 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 minimize misdiagnosis. Future work should focus on gaining a greater qualitative understanding of the diagnostic challenges from the perspective of patients and clinicians.


Cellulitis is a common infection of the deep dermis and subcutaneous tissue, with 60% of cases affecting the lower limb.[1] Clinical presentation is typically an acute infection with signs of inflammation including pain, warmth, redness and swelling.[2] A subtype of cellulitis with more pronounced superficial inflammation is known as erysipelas.[3]

Unfortunately, 31% of patients admitted from the emergency department and diagnosed as having lower-limb cellulitis are misdiagnoses.[4] Within this group of misdiagnoses, 85% have an avoidable hospital admission and 92% receive unnecessary antibiotics.[4] This burden is significant: in 2016–2017 there were 132 896 recorded cases of cellulitis managed in secondary care in the U.K., with a mean length of stay of 6 days.[5]

An important priority for cellulitis research, identified by both patients and healthcare professionals at the cellulitis Priority Setting Partnership, is diagnosis.[6] This includes research to assist clinicians in making an accurate diagnosis, identifying atypical presentation of cellulitis in patients with comorbidities and assessing for early signs or symptoms to allow prompt treatment.

A search of the Cochrane Database of Systematic Reviews, Prospero and PubMed found no previous systematic reviews looking at the challenges and facilitators when making a diagnosis of cellulitis. Identifying challenges and facilitators is an exploratory research question suited to a scoping review to gain a broad overview of this topic.[7] Such a review may also assist in identifying gaps for future research on diagnosis in lower-limb cellulitis.

The main aim of this scoping review was to explore the challenges and facilitators identified by patients and health professionals in diagnosing lower-limb cellulitis. 'Cellulitis' in this paper refers to lower-limb cellulitis only.