What is the management for an abscess under the armpit (axilla)?

Management of Axillary Abscess

Surgical incision and drainage is the primary treatment for an axillary abscess, with antibiotic therapy indicated if systemic signs of infection are present, in immunocompromised patients, if source control is incomplete, or in cases with significant surrounding cellulitis. 1

Diagnosis

• Clinical presentation typically includes:
  • Pain, swelling, and erythema in the axillary region
  • Fluctuant mass on palpation
  • Possible surrounding cellulitis
  • Systemic symptoms (fever, malaise) in more severe cases
• Point-of-care ultrasound can be helpful in unclear cases to confirm the presence of a fluid collection 2

Treatment Algorithm

1. Surgical Management

• Incision and drainage (I&D) is the cornerstone of treatment for axillary abscesses 1, 3
• Procedure steps:
  • Provide adequate anesthesia (local anesthesia with systemic analgesia)
  • Make an appropriate incision that allows complete drainage
  • Completely evacuate all purulent material
  • Explore the cavity to break up loculations
  • Irrigate with sterile saline solution
  • Consider loop drainage technique over traditional I&D 2

2. Wound Management

• For wounds larger than 5 cm, packing may reduce recurrence and complications 3
• For smaller wounds, packing may be omitted without affecting outcomes 4
• Recommend warm soaks to the area post-procedure
• Ensure adequate follow-up within 24-48 hours

3. Antibiotic Therapy

• For simple, uncomplicated abscesses after adequate I&D, antibiotics may not be necessary 5

• Indications for antibiotics include:

  • Systemic signs of infection (fever, tachycardia)
  • Immunocompromised status
  • Incomplete source control
  • Significant surrounding cellulitis 1
  • High-risk location (face, hands, genitalia)

• When antibiotics are indicated, empiric coverage should include:

  • Coverage for MRSA due to high prevalence in skin abscesses 6, 2
  • First-line oral options:
    • Trimethoprim-sulfamethoxazole (TMP-SMX) 160-320/800-1600 mg PO q12h 7
    • Doxycycline 100 mg PO q12h 7
    • Clindamycin 300-600 mg PO every 8 hours (if penicillin allergic) 7

• For severe infections requiring hospitalization:

  • Vancomycin 30-60 mg/kg/day IV in 2-4 divided doses 7
  • Duration of therapy typically 5-7 days 7

Special Considerations

• Community-acquired MRSA (CA-MRSA) is a common cause of axillary abscesses, particularly in:

  • Athletes and those who share gym equipment 6
  • People with close physical contact (team sports, military)
  • Those sharing personal items (razors, towels)

• For recurrent axillary abscesses:

  • Consider decolonization with intranasal mupirocin and chlorhexidine body washes 6
  • Evaluate for underlying conditions (diabetes, immunosuppression)
  • Consider culture-guided antibiotic therapy

Monitoring and Follow-up

• Reassess within 48-72 hours to ensure clinical improvement 7

• Monitor for complications such as:

  • Spread to deeper tissues
  • Systemic infection
  • Treatment failure requiring additional intervention

• Patient education should include:

  • Proper wound care instructions
  • When to return (increased pain, redness, drainage, fever)
  • Completion of full antibiotic course if prescribed
  • Personal hygiene measures to prevent recurrence

Prevention

• Regular hygiene practices
• Avoid sharing personal items
• Proper cleaning of exercise equipment
• Prompt treatment of skin injuries or infections

By following this structured approach to axillary abscess management, focusing on appropriate surgical drainage and selective use of antibiotics, optimal outcomes can be achieved while minimizing unnecessary antibiotic use.