Do I have to pack an abscess after drainage?

From the Guidelines

Packing an abscess after drainage is not necessary and its use should be left to individual unit policy and patient discussion. The decision to pack an abscess after drainage depends on various factors, including the size, location, and characteristics of the abscess. According to the World Journal of Emergency Surgery guidelines 1, there is no clear evidence to support the use of packing after anorectal abscess drainage. In fact, a recent Cochrane review cited in the guidelines 1 found that the use of internal dressings (packing) for the healing of perianal abscess cavities has no clear benefit in terms of time to healing, wound pain, development of fistulae, abscess recurrence, or other outcomes.

Some key points to consider when deciding whether to pack an abscess after drainage include:

• The size and complexity of the abscess: larger or complex abscesses with multiple loculations may require packing to keep the wound open and prevent premature closure.
• The location of the abscess: perianal and ischioanal abscesses are typically treated via incision and drainage of the overlying skin, while intersphincteric abscesses are drained into the rectal lumen.
• The patient's overall health and clinical condition: patients with sepsis, severe sepsis, or septic shock, immunosuppression, diabetes mellitus, and diffuse cellulitis should undergo emergent drainage.

It's worth noting that packing can be painful and costly, and its use may not add any benefit to the healing process, as suggested by a multi-center observational study 1. Therefore, the decision to pack an abscess after drainage should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances. Proper wound care, including keeping the area clean and following the provider's instructions for dressing changes, is essential regardless of whether packing is used.

From the Research

Abscess Drainage and Packing

• The need to pack an abscess after drainage is a topic of debate, with some studies suggesting that packing may not be necessary for small abscesses 2.
• A study published in 2022 found that packing wounds larger than 5 cm may reduce recurrence and complications, but wound culture and antibiotics do not improve healing 3.
• Another study from 2016 found that packing groups had more pain, and there was no difference in treatment failure rates, recurrence rates, or need for secondary interventions in non-packed wounds 4.
• A 2017 study concluded that packing after incision and drainage does not reduce the risk of recurrence or reintervention compared with not packing for abscesses less than 5 cm 2.

Alternatives to Packing

• Some studies suggest that alternatives to packing, such as loop drainage or needle aspiration, may be suitable for certain types of abscesses 5.
• A 2021 review found that ultrasound is valuable in diagnosing abscesses and guiding incision and drainage procedures, and that antibiotics, needle aspiration, and loop drainage are suitable alternatives to incision and drainage for abscesses with certain characteristics 5.
• The same review found that oral antibiotics can improve outcomes after incision and drainage, although this improvement must be weighed against potential risks 5.

Specific Types of Abscesses

• Different types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses, may require different management strategies 5.
• A 2021 review found that many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective, and that needle aspiration is the recommended first-line therapy for small breast abscesses 5.
• The same review found that dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct, and that acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible 5.