A Systematic Review of Cellulitis Guidelines: The Role of Non-Pharmacological Management in Preventing Recurrence

Abstract

Cellulitis is a common acute skin and soft tissue infection with high rates of recurrence. Historically, guidelines for care have focused on pharmacological management; however, emerging evidence supports the benefits of non-pharmacological approaches for risk mitigation and recurrence prevention. This review examined best practice guidelines for the management of cellulitis—for the inclusion of recommendations beyond antibiotics to prevent recurrence. A systematic search of seven databases was conducted, including the Guidelines International Network (GIN), the Agency for Healthcare Research and Quality and the Australian National Health and Medical Research Council clinical practice guidelines. Guidelines were included if they addressed lower limb cellulitis, were developed after 2000, published in English, appeared in a peer-reviewed journal and/or were endorsed by a health agency or government body, and contained recommendations for non-pharmacological management. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess guideline quality. Ten guidelines met the inclusion criteria. Recommendations for non-pharmacological management and recurrence prevention primarily addressed risk factors such as venous disease, oedema, tinea, skin barrier integrity and obesity. However, these recommendations were often brief and lacked actionable strategies for managing local risk factors effectively. Most guidelines scored poorly in the AGREE II assessment, particularly in rigour of development, despite performing well in scope, purpose and clarity. Furthermore, non-pharmacological strategies and recurrence prevention remain underdeveloped. Strengthening the evidence base and incorporating targeted prevention strategies will be essential to improving future guidelines, ultimately enhancing patient outcomes and reducing the burden on healthcare systems.

Trial Registration: Registered with Open Science Framework OSF: osf-registrations-7wkvf-v1