What is the recommended treatment for boils on the skin?

Treatment for Boils on Skin

Incision and drainage is the primary treatment for boils (furuncles) and simple abscesses, and antibiotics are generally not needed for uncomplicated cases. 1

Understanding Boils

Boils (furuncles) are infections of hair follicles caused primarily by Staphylococcus aureus, where suppuration extends through the dermis into the subcutaneous tissue, forming a small abscess. When infection involves several adjacent follicles, it produces a carbuncle, which is a coalescent inflammatory mass with pus draining from multiple follicular orifices.

Treatment Algorithm

First-Line Treatment

1. Incision and drainage (I&D) 1

   • Make an adequate incision to allow complete drainage
   • Thoroughly evacuate the pus
   • Probe the cavity to break up loculations
   • Simply cover the surgical site with a dry dressing

2. For small furuncles:

   • Application of moist heat may promote spontaneous drainage 1
   • Warm compresses applied several times daily

When to Add Antibiotics

Antibiotics are generally unnecessary for simple boils but should be considered in the following situations 1:

• Presence of systemic inflammatory response syndrome (SIRS):
  • Temperature >38°C or <36°C
  • Tachypnea >24 breaths per minute
  • Tachycardia >90 beats per minute
  • White blood cell count >12,000 or <400 cells/µL
• Extensive surrounding cellulitis
• Immunocompromised patients
• Multiple lesions
• Severely impaired host defenses
• Inadequate drainage
• Facial or central facial location (risk of intracranial complications)

Antibiotic Selection

When antibiotics are indicated:

• For community-acquired methicillin-resistant S. aureus (CA-MRSA) risk: Consider trimethoprim-sulfamethoxazole, doxycycline, or clindamycin
• For methicillin-sensitive S. aureus (MSSA): Consider dicloxacillin, cephalexin, or clindamycin
• Duration: 5-10 days when indicated 1

Management of Recurrent Boils

For patients with recurrent boils:

1. Search for local causes such as pilonidal cyst, hidradenitis suppurativa, or foreign material 1
2. Early drainage and culture of recurrent abscesses 1
3. Decolonization regimen for recurrent S. aureus infections 1:
   • Intranasal mupirocin twice daily
   • Daily chlorhexidine washes
   • Daily decontamination of personal items (towels, sheets, clothes)
4. Evaluation for neutrophil disorders if recurrent abscesses began in early childhood 1

Common Pitfalls and Caveats

1. Inadequate drainage: Ensure complete evacuation of pus and breaking of loculations to prevent recurrence 1

2. Unnecessary antibiotic use: Antibiotics are not needed for most simple boils after adequate I&D 1

3. Misdiagnosis: Ensure the lesion is truly a boil and not another entity such as:

   • Inflamed epidermoid cyst (which doesn't require antibiotics) 1
   • Hidradenitis suppurativa
   • Deep tissue infection requiring more extensive treatment

4. Needle aspiration: This is not recommended as it has low success rates (<25% overall and <10% with MRSA infections) 1

5. Packing: May cause more pain and does not necessarily improve healing compared to simply covering the incision site with sterile gauze 1

6. Ignoring risk factors: Pay attention to diabetes, immunosuppression, and other host factors that may complicate treatment 1

7. Missing recurrent infection patterns: Consider decolonization for patients with recurrent infections 1

The evidence strongly supports incision and drainage as the cornerstone of treatment for boils, with antibiotics reserved for specific circumstances where systemic infection or host factors increase risk. This approach minimizes antibiotic use while ensuring effective treatment of these common skin infections.