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


This review was developed using the methodological framework devised by the Joanna Briggs Institute.[7] The protocol was registered on the Centre of Evidence Based Dermatology website in October 2017.[8] We searched for papers that discussed the challenges and facilitators of diagnosing lower-limb cellulitis in primary- and secondary-care settings.

Inclusion criteria were all study designs; any language; misdiagnosis of lower-limb cellulitis, erysipelas or skin and soft-tissue infection; and all age groups, sexes, ethnicities and healthcare settings. Exclusion criteria were animal studies; laboratory in vitro studies; the terms 'cellulitis', 'erysipelas' or 'skin and soft tissue infection' not in the title or abstract; 'diagnosis' not discussed in the abstract; explicitly discussed non-lower-limb cellulitis only; conference abstracts; review articles; and not the views of patients, carers or healthcare professionals.

Databases and Search Strategy

The following databases were searched on 9 October 2017: Ovid MEDLINE In-Process & Non-Indexed Citations and Ovid MEDLINE 1946 to present (Ovid), and Ovid Embase (1980–2017). For grey literature, articles from the first 100 results in Google Scholar were included when entering the search 'challenges in the diagnosis of lower limb cellulitis'.

A search strategy was developed with an information specialist (D.G.; see Acknowledgments), using the concepts 'cellulitis', 'diagnosis' and 'challenges', with controlled vocabulary (MeSH terms and Emtree) and free-text headings (Table S1; see Supporting Information).

Study Selection

Following the search, all identified citations were uploaded into EndNote X8 (Clarivate Analytics, Philadelphia, PA, U.S.A.) and duplicates were removed manually by one reviewer (M.P.). Titles and abstracts were screened by two reviewers independently (M.P. and S.I.L.) using a protocol that was initially piloted. As the results were broad, the selected papers were coded by the challenge or facilitator identified and then grouped into themes by thematic analysis by one reviewer (M.P.). These themes were reviewed with all other reviewers (S.I.L., K.S.T. and J.K.). Three themes were further explored, with full-text papers screened by M.P. and S.I.L. independently. Disagreements between the two reviewers were resolved through discussion with a third independent reviewer (K.S.T. or J.K.).

Data Extraction and Presentation

Data were extracted by two independent reviewers (M.P. and S.I.L.). A data extraction pilot using three papers was initially carried out by two reviewers (M.P. and S.I.L.). Non-English papers were translated by colleagues proficient in that language or Google Translate. Quantitative data are presented as a narrative synthesis.