Re: Advances in the diagnosis and management of skin and soft tissue infections and two imortant subtypes

Agreement: I AgreeBody:

Dear Editor

Two important subtypes of cellulitis also need special mention. One is orbital cellulitis, due to the risk of complications such as sight impairment and risk of extension of infection to the intracranial compartment[1],[2]. The other is genital area infection, exemplified by scrotal cellulitis (which can progress to Fournier's gangrene)[3], and pelvic cellulitis[4], which can be attributable to underlying Bartholinitis[5].

Aetiological role of SGLT-2 inhibitor treatment:-
Treatment with SGLT-2 inhibitor medication is a major risk factor for genital area infections[6],[7],[8]. In turn, genital area cellulitis is sometimes complicated by the development of Fournier's gangrene, especially among men[7], and may also be complicated by the development of diabetic ketoacidosis, which may either be euglycemic[9] or hyperglycaemic[10].. The latter was also a report of Fournier's gangrene in a female patient[10].

Now that SGLT-2 inhibitor therapy has a secure role in the armamentarium for heart failure treatment it should become the standard of care to warn patients to be vigilant for symptoms of pelvic soft tissue infection and cellulitis such as pain in the pelvic and genital area. Those symptoms should be a red flag for genital area soft tissue infection and cellulitis in any patient who is on SGLT-2 inhibitor medication. Both in primary care and in secondary care patients who experience those symptoms in the context of SGLT-2 medication should be triaged for urgent medical consultation.

References
[1] Pelletier J., Koyfman A., Long B. High risk and low prevalence diseases: Orbital cellulitis. Am J Emerg Med 2023;doi. 10.1016/j.ajem.2023.02.024
[2] Yadalla D., Jayagayathri R., Padmanabam K., Ramasamy R et al. Bacterial orbital cellulitis-A review. Indian Journal of Ophthalmology 2023;71;2687-2693
[3] Elshimy G., Correa R., Alsayed M., Jyothinagaram S. Early presentation of a rare complication of sodium-glucose cotransporter-2 inhibitors 10 days after initiation: Case report and literature review. CUREUS 2019;11(7):e5173.DOI:10.7759/cureus.5173
[4] Nishimura R., Tanaka Y., Koiwai K et al. Effect of empagliflozin monotherapy on postprandial glucose and 24 hour glucose variability in Japanese patients with type 2 diabetes mellitus: a randomized, double-blind, placebo-controlled, 4-week study. Cardiovascular Diabetology 2015;14 DOI;10.1186/s12933-014-0169-9
[5] Benabderrazik B., Chaouche I., Haloua M et al. Pelvic cellulitis, a rare complication of bartholinitis: report of two cases. Radiology Case Reports 2023;18:563-566
[6] Zhou W., Xia Y., Li J., Wang F. Adverse event reporting signals for SGLT-2 inhibitor-metformin combination therapy : a disproportionality analysis of the FAERS database. Frontiers in Endocrinology 2026 DOI 10.3389/fendo.2026.1917352
[7] Cheng T-H., Lin K-C., Chuang T-M et al. SGLT2 inhibitors and external genital infection in male patients with Type 2 diabetes. JAMA Network Open 2025;8;e2534485 doi 10.1001/jamanetworkopen.2025.34485
[8] Shin H., Schneeweis s., Glynn RJ., Patorno E. Cardiovascular outcomes in patients initiating first-line treatment of Type 2 diabetes with sodium-glucose cotransporter-2 inhibitors versus metformin: A cohort study. Ann Intern Med 2022;175:927-937
[9] Moh'd Mari AA Iwuagwu CC. Euglycemic diabetic ketoacidosis , recurrent genital abscess, and proximal renal tubular acidosis with concurrent SGLT-2 inhibitor: More than an association. CUREUS 2024;16;e67481doi 10.7759/cureus.67481
[10] Kasbawala K., Stamatiades GA., Majumdar S. Fournier's gangrene and diabetic ketoacidosis associated with sodium glucose co-transporter 2(SGLT2) inhibitors: Life-threatening complications. American journal of Case reports 2020;21:e921536 DOI 10.12659/AJCR.921536

No competing Interests: YesThe following competing Interests: Electronic Publication Date: Thursday, September 17, 2026 - 20:26AI use: No, I have not used AIHighwire Comment Subject:

Advances in the diagnosis and management of skin and soft tissue infections

Workflow State: ReleasedFull Title:

Re: Advances in the diagnosis and management of skin and soft tissue infections and two imortant subtypes

Highwire Comment Response to:

Advances in the diagnosis and management of skin and soft tissue infections

Check this box if you would like your letter to appear anonymously:: Last Name: JolobeFirst name and middle initial: Oscar MEmail:

oscarjolobe@yahoo.co.uk

Address: ManchesterOccupation: retired geriatricianAffiliation: British Medical AssociationBMJ: Additional Article Info: Rapid response