Should I excise a draining abscess?

Management of Draining Abscesses

For a draining abscess, formal incision and drainage is still the primary treatment to ensure complete evacuation of all loculations and prevent recurrence, even if spontaneous drainage has already begun. 1

Rationale for Drainage of Already Draining Abscesses

• Spontaneous drainage is often incomplete and doesn't address:

  • Hidden loculations (pockets of pus)
  • Deeper extensions of the abscess
  • Complete evacuation of purulent material

• The Infectious Diseases Society of America (IDSA) guidelines clearly state that incision and drainage is the primary treatment for cutaneous abscesses 2

• Even with visible drainage, formal incision and drainage ensures:

  • Complete evacuation of all purulent material
  • Breaking up of loculations
  • Adequate exposure to prevent premature closure of the skin surface while deeper infection remains

Technique for Draining an Already Draining Abscess

1. Make an adequate incision over the point of maximal fluctuance
2. Perform blunt dissection to break up all loculations
3. Explore the cavity thoroughly without aggressive probing
4. Consider placement of a drain or packing for wounds larger than 5 cm 3

When Antibiotics Are Indicated

Antibiotics should be added to incision and drainage in cases with:

• Severe or extensive disease involving multiple sites
• Rapid progression with associated cellulitis
• Signs and symptoms of systemic illness
• Associated comorbidities or immunosuppression
• Extremes of age
• Abscess in difficult-to-drain areas (face, hand, genitalia)
• Associated septic phlebitis
• Lack of response to incision and drainage alone 2

Special Considerations

• For anorectal abscesses, the World Journal of Emergency Surgery strongly recommends surgical approach with incision and drainage even if spontaneously draining 2

• Timing of surgery should be based on the presence and severity of sepsis:

  • Emergent drainage for patients with sepsis/septic shock, immunocompromised patients, diabetics, or those with diffuse cellulitis
  • Urgent drainage (within 24 hours) for cases without these factors 2

• For small, simple abscesses in immunocompetent patients without systemic signs of sepsis, outpatient management may be considered 2

Common Pitfalls to Avoid

1. Assuming spontaneous drainage is sufficient - this often leads to recurrence and complications
2. Inadequate incision size - prevents complete drainage and exploration
3. Failure to break up loculations - leaves pockets of infection
4. Premature closure of the drainage site - can lead to reaccumulation
5. Unnecessary antibiotic use in simple, adequately drained abscesses without systemic signs of infection

Follow-up Care

• Monitor for signs of infection and follow up within 48-72 hours to assess for reaccumulation
• Remove packing within 5 days to minimize complications while ensuring adequate drainage 1
• Consider wound cultures only in high-risk patients or those with risk factors for multidrug-resistant organisms

Remember that while some bacterial abscesses in specific locations (like liver, brain, or kidney) may respond to antimicrobial therapy without drainage 4, cutaneous abscesses generally require formal incision and drainage even when spontaneously draining, to ensure complete resolution and prevent recurrence.