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subcutaneous abscess; boil

Etiology: 1) cellulitis 2) lymphadenitis 3) colonization with Staphylococcus aureus (MRSA common) Pathology: 1) mixture of anaerobes & aerobes 2) Staphylococcus aureus is the predominant organism Clinical manifestations: 1) painful induration 2) localized erythema 3) most common sites: neck, axilla, groin 4) may occur at any site on the skin *images [6] Management: 1) incision & drainage (I&D) a) fine needle aspiration with 22 guage needle if fluctuance is questionable b) scalpel incision c) larger abscesses 1] probe with a sterile swab & break up loculations 2] lavage with saline or hydrogen peroxide 3] pack with 1/4-1/2 inch strip gauze 4] cover with 4 x 4 inch gauze pad 5) re-evalute in 24 hours (face) or 24-48 hours 6) repack wound until erythema, drainage & induration resolve 7) topical dressing until wound has healed 2) indications for antibiotic coverage a) immunosuppressed patients b) patients with facial lesions c) systemic manifestations (fever, tachycardia) d) diabetes mellitus e) peripheral vascular disease f) abscesses > 2 cm in diameter g) extensive surrounding erythema suggesting cellulitis [10] h) not necessary for I&D in children [2] 3) antibiotic agents a) avoid beta-lactam due to high incidence of MRSA - especially recently hospitalized patients or nursing home residents [10] b) TMP/SMX (320 mg/1600 mg twice a day) for 7 days results in marginally higher cure rate (93% vs 86%) [7] - TMP/SMX if streptococci not a concern [3] c) TMP/SMX or clindamycin for 10 days improves short-term outcomes in patients after I&D of small skin abscesses [9] b) doxycycline if TMP-SMX contraindicated c) clindamycin, penicillin, cephalexin if non-purulent (Streptococcus) d) linezolid e) intravenous vancomycin in hospitalized patients [1] 4) prevention a) hygiene b) intranasal mupirocin to reduce nasal colonization with Staphyloccus

Related

perirectal abscess

Specific

carbuncle (carbunculosis) furuncle vulvar abscess

General

abscess

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 17 American College of Physicians, Philadelphia 1998, 2009, 2015
  2. Duong M et al Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med 2009 May 1 PMID: 19409657 http://dx.doi.org/10.1016/j.annemergmed.2009.03.014
  3. Schmitz GR et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010 Sep; 56:283. PMID: 20346539
  4. Kemper AR et al. Management of skin abscesses by primary care pediatricians. Clin Pediatr (Phila) 2011 Jun; 50:525. PMID: 21262755
  5. Singer AJ and Talan DA Management of Skin Abscesses in the Era of Methicillin- Resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039-1047. March 13, 2014 PMID: 24620867 http://www.nejm.org/doi/full/10.1056/NEJMra1212788
  6. DermNet NZ. Cutaneous abscess (images) http://www.dermnetnz.org/bacterial/abscess.html
  7. Talan DA, Mower WR, Krishnadasan A et al Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med 2016; 374:823-832. March 3, 2016 PMID: 26962903 http://www.nejm.org/doi/full/10.1056/NEJMoa1507476
  8. Wilbur MB, Daum DS, Gold HS Skin Abscess N Engl J Med 2016; 374:882-884. March 3, 2016 PMID: 26962909 http://www.nejm.org/doi/full/10.1056/NEJMclde1600286
  9. Daum RS, Miller LG, Immergluck L et al A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med 2017; 376:2545-2555. June 29, 2017 PMID: 28657870 http://www.nejm.org/doi/full/10.1056/NEJMoa1607033
  10. NEJM Knowledge+ Dermatology