Confusable diagnoses · PANCE / PANRE

Cellulitis vs Necrotizing Fasciitis

Cellulitis and Necrotizing Fasciitis are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.

Cellulitis vs Necrotizing Fasciitis at a glance

  • Cellulitis: Acute bacterial infection of the dermis and subcutaneous tissue, most often caused by beta-hemolytic streptococci or Staphylococcus aureus.
  • Necrotizing Fasciitis: Rapidly progressive, life-threatening deep soft tissue infection requiring emergent surgical debridement and broad-spectrum antibiotics.
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Side-by-side comparison

FeatureCellulitisNecrotizing Fasciitis
At a glanceAcute bacterial infection of the dermis and subcutaneous tissue, most often caused by beta-hemolytic streptococci or Staphylococcus aureus.Rapidly progressive, life-threatening deep soft tissue infection requiring emergent surgical debridement and broad-spectrum antibiotics.
Classic presentationUnilateral lower-leg cellulitis is extremely common; bilateral lower-leg 'cellulitis' is almost never cellulitis — consider stasis dermatitis,…Patient with severe pain disproportionate to exam, rapidly spreading edema, hemorrhagic bullae, and systemic toxicity — emergency surgical exploration…
Workup / key labsClinical diagnosis. IDSA stratifies into mild, moderate, severe and purulent vs non-purulent for treatment selection.; CBC, BMP, lactate if systemic toxicity;…Clinical diagnosis confirmed at surgical exploration: gray, necrotic, easily dissected fascia ('finger test'); lack of bleeding; foul-smelling discharge.…
ImagingBedside ultrasound to differentiate cellulitis (cobblestoning) from abscess (anechoic collection); Plain films for foreign body, soft tissue gas (necrotizing…Plain films may show soft tissue gas (not always present); CT with contrast (most useful): fascial thickening, gas, fluid tracking along fascia, lack of…
First-line treatmentNon-purulent cellulitis (likely beta-hemolytic strep):; • Mild outpatient: oral beta-lactam — cephalexin 500 mg PO QID, dicloxacillin 500 mg PO QID, or…Emergent surgical debridement is the cornerstone — every hour of delay increases mortality (Wong 2003); Broad-spectrum empiric antibiotics immediately:; •…

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Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants.