What is the appropriate management for a 28-year-old female with a history of Hidradenitis Suppurativa (HS) presenting with a growing and painful skin abscess on the right breast, despite using warm compresses, and with a history of previous incisions and drainages (I&D's)?

From the Guidelines

This patient requires incision and drainage (I&D) of the breast abscess, followed by appropriate antibiotic therapy. I would perform I&D under local anesthesia, ensuring complete drainage of the purulent material and breaking up any loculations. Given her history of hidradenitis suppurativa (HS) and previous I&Ds, I would start empiric antibiotic therapy with clindamycin 300mg orally three times daily for 7-10 days, as recommended by the Infectious Diseases Society of America 1. Alternatively, trimethoprim-sulfamethoxazole DS (800mg/160mg) twice daily could be used if MRSA is suspected despite her negative history. The patient should continue warm compresses for 15-20 minutes 3-4 times daily after the procedure to promote drainage and healing. She should be instructed to keep the area clean and dry, changing dressings as needed. Follow-up should be scheduled in 48-72 hours to assess response to treatment. Some key points to consider in the management of this patient include:

• The importance of proper wound care and drainage to prevent further complications 1
• The need for empiric antibiotic therapy in patients with severe or extensive disease, or those with signs of systemic illness 1
• The role of clindamycin and trimethoprim-sulfamethoxazole as appropriate antibiotic options for the treatment of skin and soft tissue infections 1
• The importance of follow-up and monitoring for signs of treatment failure or complications 1

From the Research

Patient Presentation

• A 28-year-old female presents with a skin abscess on the right breast, which has grown in size and become more painful over the past 2 days despite using warm compresses.
• She has a significant past medical history of Hidradenitis Suppurativa (HS) and has had previous incision and drainage (I&D) procedures.
• She denies any past history of MRSA, fever, chills, or nausea and vomiting.

Management of Skin Abscesses

• According to 2, most simple abscesses can be diagnosed upon clinical examination and safely managed in the ambulatory office with incision and drainage.
• Wound culture and antibiotics do not improve healing, but packing wounds larger than 5 cm may reduce recurrence and complications.
• A study by 3 found that systemic antibiotics, when compared with a placebo, do not significantly improve cure rates in patients with simple abscesses after incision and drainage.
• Another study by 4 suggests that needle aspiration is the recommended first-line therapy for small breast abscesses, and antibiotics may be considered in certain cases.

Role of Antibiotics in Abscess Management

• A review by 5 found that post-procedural antibiotics may not be necessary for uncomplicated abscesses, and their use should be considered on a case-by-case basis.
• A prospective study by 6 found that antibiotic agents are not necessary for uncomplicated subcutaneous abscesses after I&D, and these cases can be managed safely on an outpatient basis without any increase in morbidity.

Considerations for Hidradenitis Suppurativa

• According to 4, acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence.
• However, the patient's history of HS and previous I&D procedures should be taken into account when determining the best course of management.