Abstract
Introduction:
Cellulitis is one of the significant causes of death among skin diseases in the United States, with an estimated 14.5 million cases occurring each year, accounting for a healthcare burden of $3.7 billion.
Methods:
Public data from the Centers for Disease Control and Prevention database were used to extract death certificates for cellulitis-related deaths in the United States. Disparities in trends of certain variables, such as sex, race, state, census region, and metropolitan status, were identified for calculating annual percent change through the Joinpoint Regression Program.
Results:
A total of 99 094 cellulitis-related deaths were identified (44.46% males, 55.53% females). Overall, age-adjusted mortality rate increased from 79.7 [95% confidence interval (CI): 76.7–82.7] in 1999 to 108.6 (95% CI: 105.8–111.4) per 1 000 000 population in 2023. Joinpoint analysis revealed a slight increase from 1999 to 2008, a sustained rise from 2008 to 2019, and a steep rise from 2019 to 2023. Non-Hispanic White individuals [age-adjusted mortality rates (AAMR): 97.1; 95% CI: 93.8–100.3] and the Midwest Census Region (AAMR: 99.6; 95% CI: 98.2–100.9) had the highest mortality rates.
Conclusions:
Cellulitis mortality has risen in the United States over 25 years, especially among men, non-Hispanic Whites, and rural populations. Contributing factors include comorbidities, healthcare access, and disparities. Despite low inhospital mortality, frequent admissions highlight treatment gaps and inequalities.
Keywords: age adjusted mortality rates, CDC WONDER, cellulitis, mortality trends
Introduction
A bacterial infection of the skin and soft tissues, cellulitis, arises when the immune system, circulatory system, or physical skin barrier is compromised. Diabetes, obesity, and advanced age are indispensable risk factors for cellulitis since they are linked to disruptions in all of these parts[1,2]. Cellulitis has an incidence rate of 24.6 per 1000 person-years, and it is far more prevalent in men and those between the ages of 45 and 64[3]. Although the majority of cellulitis cases are nonculturable, the causative bacteria are unknown. About 15% of cases in which organisms are identified are caused by β-hemolytic Streptococcus and Staphylococcus aureus. An estimated 14.5 million cases of cellulitis occur each year in the United States, accounting for $3.7 billion in ambulatory care costs alone, thus indicating a significant healthcare burden[4]. According to the Global Burden of Disease, there were approximately 43 million cases of cellulitis in 2019 (555 cases per 100 000 people), which resulted in 18 069 fatalities[5].
HIGHLIGHTS
Cellulitis deaths rose in older U.S. adults over the past 24 years.
Non-Hispanic Whites and the Midwest region had the highest cellulitis death rates.
Mortality was higher among males and those in rural areas.
Gaps in access and care may drive cellulitis-related health disparities.
Though cellulitis is generally seen as a curable disorder, especially with prompt diagnosis and the use of antibiotics, delayed treatment among older persons – particularly those with major comorbidities or obstacles to treatment – can lead to severe consequences or even death. In this context, cellulitis can act as a terminal event in the trajectory of chronic disease, rather than an isolated infection.
While cellulitis is common and a significant healthcare burden, no studies have examined trends and disparities in cellulitis mortality among older adults in the United States The objective of this study is to examine trends in cellulitis mortality by gender, race, and geography. Recognizing these disparities can influence policies aimed at targeting high-risk populations and the allocation of resources.
As non-U.S.-based researchers, we recognized an essential lack in the literature of long-term, population-based findings describing cellulitis mortality trends in older Americans. Even though it places a substantial burden, there is sparse evidence describing variation by gender, geography, and demographics. Encouraged by this gap in needed information, we conducted an extensive 24-year analysis using the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research (CDC WONDER) database, adhering to the TITAN 2025 guidelines[6] in order to gain a deeper understanding of mortality patterns and disparities, and to provide actionable information for impending public health efforts.
Methods
Patient eligibility
The CDC WONDER database was used to identify cellulitis-related deaths in the United States by analyzing multiple cause-of-death public use records, where cellulitis was listed either as a contributing or as the underlying cause[7]. Cellulitis cases were identified with the International Classification of Diseases, 10th Revision Clinical Modification (ICD-10-CM) code L03. Only decedents with cellulitis (L03) listed as a primary or contributing cause were included. Heart failure (I50) is discussed as a contextual comorbidity rather than being part of the inclusion criteria. Older adults were defined as individuals aged 65 years or older, which is consistent with previous epidemiological studies. The study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines and was exempted from the Institutional Review Board approval as it utilizes publicly available de-identified government data, which qualifies for nonhuman subjects research[8].
Abstraction of data
Data on cellulitis-related deaths were collected from 1999 to 2023, including demographics (sex and race/ethnicity) and regional factors (state and urban–rural classification). Racial and ethnic groups were categorized as non-Hispanic (NH) White, NH Black, Hispanic/Latino, NH American Indian/Alaskan Native, and NH Asian/Pacific Islander following the U.S. Office of Management and Budget Guidelines and CDC WONDER classifications[9]. The National Center for Health Statistics Urban-Rural Classification Scheme categorized geographic areas as nonmetropolitan (<50 000), medium/small metropolitan (50 000–999 999), and large metropolitan (≥1 million)[10]. For regional classification, the Census Bureau categorized regions as Northeast, Midwest, South, and West.
Synthesis of data
For cellulitis, we computed age-adjusted mortality rates (AAMR) per 1000 000 for each category (year, sex, race/ethnicity, state, census region, and metropolitan status) using the year 2000 U.S. standard population as the reference[11]. The CDC WONDER database provides the population estimates and the corresponding 95% confidence intervals (CIs) for AAMRs. Further, the age group specification (65–85 years) was uniformly applied across all stratifications following the inclusion criteria of older adults. We used the Joinpoint Regression Program and applied log-linear regression methods to calculate annual percent changes (APCs) in AAMRs over time[12]. Further, a Monte Carlo permutation approach was implemented to compute APCs and their 95% CIs at each joinpoint. Statistical significance was assessed at the P-value of <0.05 using a two-tailed t-test.
Results
Annual and sex-stratified trends for cellulitis-related AAMR
A total of 99 094 deaths were attributed to cellulitis among older adults (≥65 years) from 1999 to 2023, including 56% of males, while the rest were females. Overall, the AAMR increased from 79.7 (95% CI: 76.7–82.7) in 1999 to 108.6 in 2023, showing a stark rise from 2019 to 2023 (APC: 3.49; 95% CI: 1.45−6.87; P = 0.023595). Males (99.6) had higher mortality rates than females (83.0) with both experiencing a sharp incline in AAMRs between 2019 and 2023 as reflected by the APCs of 3.85 (95% CI: 1.73–7.74; P = 0.011198) and 3.45 (95% CI: 1.40–7.13; P = 0.012398), respectively (Figs 1, 2) (Supplemental Digital Content Table S1, available at: http://links.lww.com/MS9/A993, Supplemental Digital Content Table S2, available at: http://links.lww.com/MS9/A994, Supplemental Digital Content Table S7, available at: http://links.lww.com/MS9/A999).
Figure 1.
Trends in overall age-adjusted mortality rates of cellulitis among older adults aged 65–85+ years in the United States, 1999–2023. *Indicates that the annual percentage change (APC) is significantly different from zero at α = 0.05.
Figure 2.
Comparison of trends in age-adjusted mortality rates of cellulitis by sex among older adults aged 65–85+ years in the United States, 1999–2023. *Indicates that the annual percentage change (APC) is significantly different from zero at α = 0.05.
Cellulitis-related AAMR stratified by racial background
The majority of the deaths occurred in NH White (87%) individuals, with lesser frequencies in NH African American (6%), Hispanic (4%), and NH Asian (2%) populations, respectively. Likewise, the total AAMR in NH White (97.1) individuals was doubled that of NH African American (68.3), Hispanic (56.9), and NH Asian (39.2) populations (Supplemental Digital Content Table S1, available at: http://links.lww.com/MS9/A993).
A significant decline in mortality rates was observed from 1999 to 2011 among Hispanic (APC: −2.20; 95% CI: −9.05, −0.36; P = 0.012398) and NH African Americans (APC: −2.11; 95% CI: −8.77, −0.67; P = 0.017596) followed by a significant incline afterwards in Hispanics until 2023 (APC: 1.83; 95% CI: 0.59–6.22; P = 0.005999). NH Whites experienced a significant rise in AAMR from 2019 to 2023 (APC: 3.93; 95% CI: 2.02–7.27; P = 0.007199). In contrast, a significant decline was noted in NH Asians from 2006 to 2023 (APC: −2.27; 95% CI: −8.92, −1.24; P = 0.014797) (Fig. 3, Supplemental Digital Content Table S3, available at: http://links.lww.com/MS9/A995, Supplemental Digital Content Table S7, available at: http://links.lww.com/MS9/A999).
Figure 3.
Comparison of trends in age-adjusted mortality rates of cellulitis by race/ethnicity among older adults aged 65–85+ years in the United States, 1999–2023. *Indicates that the annual percentage change (APC) is significantly different from zero at α = 0.05.
Cellulitis-related AAMR stratified by geography
Significant disparities were recorded across various geographic subgroups, with nonmetropolitan areas (98.5) represented by the highest AAMR, followed by medium/small metropolitan areas (96.0) and large metropolitan areas (79.6). AAMR rose significantly throughout the study in nonmetropolitan areas, whereas it inclined sharply after 2011 till 2023 in medium/small metropolitan areas with associated APCs of 1.88 (95% CI: 1.60–2.23; P ≤ 0.000001) and 2.30 (95% CI: 1.40–5.85; P = 0.033993), respectively. Regionally, the Midwest (101.9) and West (98.3) represented the highest rates, followed by the South (81.4) and the Northeast (82.6). Among states, Hawaii showed the peak AAMR (141.2), whereas Florida had the lowest (56.7). Further the states (Alaska, Hawaii, Montana, South Dakota, Utah, and Washington) of top 90th percentiles had approximately doubled the AAMRs compared to those in the inferior 10th percentile (Arkansas, District of Columbia, Florida, Georgia and Louisiana) (Figs 4, 5) (Supplemental Digital Content Table S4, available at: http://links.lww.com/MS9/A996, Supplemental Digital Content Table S5, available at: http://links.lww.com/MS9/A997, Supplemental Digital Content Table S6, available at: http://links.lww.com/MS9/A998, Supplemental Digital Content Table S7, available at: http://links.lww.com/MS9/A999).
Figure 4.
Trends in age-adjusted mortality rates of cellulitis by urbanization among older adults aged 65–85+ years in the United States, 1999–2020. *Indicates that the annual percentage change (APC) is significantly different from zero at α = 0.05.
Figure 5.
State-level age-adjusted mortality rates of cellulitis among older adults aged 65–85+ years in the United States, 1999–2020.
Discussion
Our investigation of CDC data for 24 years has demonstrated an increase in cellulitis mortality from 1999 to 2023, which disproportionately affects men, NH White individuals, and those residing in nonmetropolitan regions of the United States.
Cellulitis is widely considered as a treatable condition but factors such as delayed care, rising antibiotic resistance and comorbidities could significantly contribute to the rising mortality rates as observed in our study with studies showing that comorbidities such as decompensated liver cirrhosis can increase cellulitis mortality rates by 100% especially in those with gram negative infections or complications including septic shock or necrotizing fasciitis[13]. Further, Figtree et al discovered a 2.5% inhospital mortality rate among 395 cellulitis patients, with 28.4% experiencing complications. However, these rates are much lower than those represented in the preantibiotic era, bacteremia, and low albumin (<30 g/L), which remain risk factors for mortality and prolonged hospitalization[14]. Likewise, a Thai study found only 0.3% mortality among hospitalized cellulitis patients, which can be due to effective antibiotic therapy against beta-hemolytic streptococci and methicillin-susceptible staphylococcus aureus (MSSA)[15]. These findings showed that systemic healthcare factors and population-level risk may lead to an increase in cellulitis mortality in the United States, and are in contrast with the rising mortality rates observed in our study.
Moreover, Cranendonk et al observed that patients with severe cellulitis were less critically ill than those with necrotizing fasciitis but showed similar mortality rates due to the increased prevalence of chronic comorbidities such as cardiovascular and immunodeficiency conditions[16]. For instance, a study by the national health insurance (NIH) indicated a higher incidence rate of cellulitis as well as increased mortality in breast cancer patients with lymphedema[17].
Similar to the sex-based disparities that were observed in our analysis, the research by Carratalà et al found that overall mortality due to cellulitis was higher in males, possibly due to the higher prevalence of comorbidities such as congestive heart failure, morbid obesity, shock, hypoalbuminemia, renal insufficiency, and Pseudomonas aeruginosa as compared to women[18]. Likewise, another study reported a greater risk of cellulitis in men aged 45–64 years[3]. However, a national trend analysis of hospitalizations for cellulitis from 2016 to 2022 showed lower rates of admission among women but increased crude inhospital mortality relative to men. This is probably because the diagnosis is made at an older age in women (65–75 and >80 years) when comorbidities and complications like sepsis are more common[19].
Existing literature frequently discusses cellulitis in a broader context of skin and soft tissue infections (SSTIs), while the data specific to cellulitis remain limited, making it challenging to assess the disparities associated with the condition itself. However, addressing this potential gap, our study discovered the highest cellulitis-related death rates among NH Whites. Aligning with our findings, a UK study identified white ethnicity as a risk factor for acute lower limb cellulitis, possibly related to hypotheses such as differences in PH and reduced barrier function in the lighter skin types[20]. Conversely, some studies have found increased risk of SSTIs in the NH African American population and linked it to socioeconomic disparities and increased prevalence of MRSA and diabetes in this population[21,22]. According to a cross-sectional analysis from 2012 to 2017, NH White patients were less frequently hospitalized, which may reflect the differences in Medicaid coverage, but when hospitalized, they were older and had more severe illness[23]. Further ICU surveys of cellulitis patients confirmed the predominance of the NH White (83%) population with high rates of comorbidities, including cardiovascular inadequacies (43%) and immunocompromised status (39%)[16]. These findings indicate that while minority groups tend to suffer disproportionately from infectious complications owing to socioeconomic burdens, NH Whites, especially those who are older and frail, experience greater severity and mortality, highlighting a need for including NH Whites in health disparity narratives who might be underrepresented in minority centric analysis.
Our study also found higher cellulitis mortality rates in the Midwest and nonmetropolitan areas. Similar trends were observed in Western Australia, where summer heat and factors like varicose veins, lymphedema, tinea pedis, heart failure, and obesity have been reported to contribute to increased lower leg cellulitis[24]. Furthermore, Peterson et al showed increased cellulitis admissions during warmer temperatures, which they related to venous insufficiency following vasodilation and fluid shifts, while reduced compression therapy adherence may also increase swelling and susceptibility[25].
Nonmetropolitan areas frequently face barriers like delayed presentation, limited availability of antibiotics or healthcare providers, increasing the risk of cellulitis. Studies from Ghana and India have demonstrated an increased risk of cellulitis in rural populations and attributed it to factors including trauma, barefoot walking, diabetes, and delayed presentation, underscoring the need for targeted interventions such as expanded outpatient antibiotic access, teledermatology, and improved cellulitis awareness among primary care physicians[26,27].
Lastly, our analysis revealed a stark rise in mortality rates post-2019, reflecting the impact of COVID-19, which had significantly affected the care-seeking behavior, hospital access, and infection control systems, leading to delayed diagnosis and treatment. However, changes in healthcare delivery and coding practices might also have contributed to this trend. Our findings thus indicate that whereas cellulitis itself is perhaps not commonly life-threatening, its appearance in medically frail older patients, especially males or those in rural settings, may serve as an index event signaling extensive systemic failures or delays in care.
Study limitations
There are a number of limitations to this study. First, it uses death certificate information, which can potentially underreport or misclassify cellulitis deaths, thus diminishing the validity of our outcome measure. Second, the lack of clinical information, such as causative organisms, treatment modalities, and severity scores, prevents us from putting the findings into a clinical perspective. Moreover, important variables such as socioeconomic status, access to care, and patient comorbidity were lacking, precluding examination of potential confounders. Thus, due to the absence of patient-level data, we are unable to conduct multivariable analysis. Regional variation in coding behavior and healthcare delivery can also introduce bias. Because this is an observational, retrospective analysis, causation is not assumed. These limitations limit the strength and generalizability of our findings, especially for stratified subgroup analyses. Linked clinical datasets and prospective designs in future studies are required to better quantify and contextualize cellulitis-related mortality.
Conclusion
Our 25-year study shows rising cellulitis mortality in the United States, most striking among men, NH Whites, and rural populations. Mortality is highest in the Midwest and nonmetropolitan areas, with the highest all-cause trend in Hawaii. Underlying causes are comorbidities, limited access to care, and environmental causes. Frequent hospitalization and complications emphasize the need for prompt antibiotics and outpatient care. Minimizing mortality and improving outcomes may necessitate addressing disparities and risk factors. Our results indicate that mortality from cellulitis captures delayed treatment and high comorbidity in frail, older adults, particularly in disadvantaged communities. Measures to enhance early diagnosis, outpatient treatment, and access to rural care may reduce preventable deaths. Subsequent research correlating clinical data with mortality registers is required to elucidate underlying drivers.
Acknowledgements
None.
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.lww.com/annals-of-medicine-and-surgery.
Published online 15 October 2025
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Ethical approval
The present study does not involve direct data collection from human subjects or animals. All data used in this study were obtained from previously published and publicly available sources, adhering to the ethical guidelines of the respective studies. No identifiable patient information is presented in this study.
Consent
Not applicable.
Sources of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author contributions
M.S.B.F.: Conceptualization, writing – original draft, supervision, writing – review & editing, investigation, formal analysis, data curation, validation, visualization, and project administration. S.U.M.: Writing – original draft, writing – review & editing, resources, investigation and data curation, validation, and project administration. M.J.: Project administration, data curation, resources, and writing – original draft. S.T.H.: Project administration, data curation, validation, writing – review & editing, formal analysis, and software. M.B.M.: Conceptualization, formal analysis, and visualization. K.U.E.M.: Validation, resources, and investigation. S.C.: Writing – original draft, resources, and methodology. S.S.: Resources and investigation. M.I.K.: Project administration and resources.
Conflicts of interest disclosure
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Research registration unique identifying number (UIN)
Not applicable for this type of article (CDC WONDER analysis original article).
Guarantor
Muhammad Idrees Khan.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data availability statement
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.