From the Guidelines
Packing is no longer routinely indicated for most abscesses, and current evidence suggests that simple incision and drainage (I&D) alone is sufficient for uncomplicated abscesses, without the need for packing. The use of packing after drainage of an anorectal abscess remains unproven, and a recent Cochrane review 1 found that it is unclear whether using internal dressings (packing) for the healing of perianal abscess cavities influences time to healing, wound pain, development of fistulae, abscess recurrence, or other outcomes.
Some key points to consider when managing anorectal abscesses include:
- The primary treatment of anorectal abscesses remains surgical drainage, with the timing being dictated by the severity and nature of any sepsis 1.
- In fit, immunocompetent patients with a small perianal abscess and without systemic signs of sepsis, outpatient management may be considered 1.
- The risk factors associated with recurrence are inadequate drainage, loculations, horseshoe-type abscess, and time from disease onset to incision 1.
- A recent multi-center observational study found that packing is costly and painful and does not add benefit to the healing process 1.
After draining the abscess, the wound should be left open with minimal debridement of the cavity edges to allow continued drainage. For larger or complex abscesses (>5 cm), those in sensitive areas, or those with significant surrounding cellulitis, a short-term loose packing for 24-48 hours may occasionally be used to maintain the opening and facilitate drainage. However, tight packing should be avoided as it can cause pain and potentially delay healing. Following I&D, patients should be instructed to clean the area with soap and water 1-2 times daily, apply clean dressings, and monitor for signs of worsening infection such as increased pain, redness, swelling, or fever. The shift away from routine packing is based on studies showing equivalent healing rates and less pain with non-packing approaches, while also reducing the need for follow-up visits for packing changes. Antibiotics are typically only needed for abscesses with extensive cellulitis, systemic symptoms, or in immunocompromised patients.
From the Research
Indications for Packing in Abscesses
- The use of packing in abscesses is a topic of ongoing debate, with some studies suggesting that it may not be necessary for all cases 2, 3.
- A study published in the Journal of Pediatric Surgery found that incision and drainage without packing was a safe and effective technique for subcutaneous abscesses 2.
- Another study published in The Journal of the Oklahoma State Medical Association found that packing did not reduce the risk of recurrence or reintervention in non-diabetic, non-immunocompromised individuals with skin abscesses less than 5 cm 3.
Exceptions and Considerations
- However, a study published in Primary Care suggested that packing wounds larger than 5 cm may reduce recurrence and complications 4.
- The use of packing may also be considered in cases where there is a high risk of complications or recurrence, such as in immunocompromised patients 5.
- A study published in The Journal of Emergency Medicine found that the use of povidone-iodine as a treatment adjunct in patients with superficial skin abscesses did not confer any significant benefit over incision and drainage alone, and was associated with a higher rate of adverse events 6.
Current Recommendations
- The current evidence suggests that packing may not be necessary for all cases of abscesses, and that incision and drainage alone may be sufficient for uncomplicated cases 2, 3, 5.
- However, the decision to use packing should be made on a case-by-case basis, taking into account the size and location of the abscess, as well as the patient's overall health and risk factors 4, 5.