What is the treatment for a furuncle?

Treatment of Furuncles

Incision and drainage is the recommended treatment for large furuncles, while small furuncles can be effectively managed with application of moist heat to promote spontaneous drainage. 1

Understanding Furuncles

Furuncles (boils) are deep infections of hair follicles caused primarily by Staphylococcus aureus, where suppuration extends through the dermis into subcutaneous tissue, forming a small abscess. They appear as inflammatory nodules with overlying pustules through which hair emerges.

Treatment Algorithm

For Small Furuncles:

• Apply moist heat/warm compresses to promote spontaneous drainage 1
• No systemic antibiotics needed unless complications present

For Large Furuncles:

• Incision and drainage is the primary treatment (strong, high evidence) 1
• Simply cover the surgical site with a dry dressing after drainage 1
• Probing the cavity to break up loculations may be necessary 1

Antibiotic Therapy:

• Systemic antibiotics are generally unnecessary for uncomplicated furuncles 1
• Antibiotics should be added ONLY if:
  • Fever or systemic symptoms are present
  • Extensive surrounding cellulitis exists
  • Patient has SIRS (temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or abnormal WBC) 1
  • Patient has markedly impaired host defenses 1

Special Considerations

Gram Stain and Culture:

• Not routinely needed for typical cases 1
• Consider for recurrent cases or treatment failures

Carbuncles:

• Carbuncles (coalescent inflammatory mass with multiple draining follicular orifices) require incision and drainage in all cases 1
• More common in patients with diabetes, especially on the back of the neck

Pitfalls to Avoid:

• Avoid packing the wound with gauze after drainage as it may cause more pain without improving healing 1
• Avoid needle aspiration as it has low success rates (25% overall, <10% with MRSA) 1
• Don't prescribe antibiotics routinely for uncomplicated furuncles

Management of Recurrent Furunculosis

For patients with recurrent furuncles:

1. Search for local causes (pilonidal cyst, hidradenitis suppurativa, foreign material) 1
2. Consider decolonization regimen for S. aureus carriers:
   • Intranasal mupirocin twice daily for 5 days
   • Daily chlorhexidine washes
   • Daily decontamination of personal items (towels, sheets, clothes) 1
   • For nasal carriers, application of mupirocin ointment twice daily for the first 5 days each month reduces recurrences by ~50% 1
3. For persistent recurrent cases, consider clindamycin 150 mg daily for 3 months (reduces subsequent infections by ~80%) 1
4. Improve personal hygiene and consider antibacterial soaps like chlorhexidine 1
5. Evaluate for neutrophil disorders if recurrent abscesses began in early childhood 1

By following this evidence-based approach, most furuncles can be effectively managed with minimal complications and reduced risk of recurrence.