What is the treatment for a ruptured skin abscess?

Treatment of Ruptured Skin Abscess

The definitive treatment for a ruptured skin abscess is incision and drainage (I&D) with culture of the wound, followed by appropriate wound care and consideration of antibiotics based on specific clinical factors. 1

Initial Management

Drainage and Wound Care

• Complete evacuation of any remaining purulent material is essential, even if the abscess has spontaneously ruptured
• Probe the cavity to break up loculations and ensure adequate drainage 1
• For larger abscesses (>5 cm), consider packing to prevent premature closure and reduce recurrence rates 2
• For smaller abscesses, simply covering with a dry dressing is usually sufficient 1
• Consider deroofing technique (removing skin overlying the abscess) for lower recurrence rates compared to simple I&D 1

Culture and Antibiotic Considerations

• Obtain wound culture to identify causative agent and determine antibiotic susceptibility 3
• Antibiotics are not always necessary for adequately drained abscesses <5 cm in immunocompetent patients 4
• However, recent evidence suggests improved outcomes with antibiotics regardless of abscess size 5
• Indications for antibiotics include:
  • Abscess >5 cm (significant predictor of hospitalization) 4
  • Surrounding cellulitis or extensive erythema
  • Systemic symptoms (fever)
  • Immunosuppression or diabetes mellitus
  • Failed initial treatment
  • High-risk location

Antibiotic Selection (if indicated)

First-line options:

• Amoxicillin-clavulanate 875/125 mg PO twice daily for 7 days 1
• For MRSA coverage (or high local MRSA prevalence):
  • Trimethoprim-sulfamethoxazole 160-320/800-1600 mg PO twice daily for 7 days 1, 6
  • Doxycycline 100 mg PO twice daily (not for children <8 years or pregnant women) 1

Special considerations:

• For patients with sepsis, severe sepsis, immunosuppression, or diabetes, consider emergent drainage and IV antibiotics 1
• Fit, immunocompetent patients with small abscesses and no systemic signs can be managed as outpatients 1

Follow-up Care

• Re-evaluate in 48-72 hours to assess healing progress 1
• Warm soaks can promote continued drainage 1
• Provide appropriate pain management with acetaminophen or NSAIDs 1
• Complete excision of any underlying cyst should be considered once acute inflammation resolves to prevent recurrence 1

Prevention of Recurrence

• Good hygiene practices
• Not sharing personal items
• Consider decolonization strategies for recurrent staphylococcal infections 3, 1
• For recurrent abscesses, consider screening for MRSA colonization (nasal, skin) 3

Pitfalls to Avoid

• Inadequate drainage is associated with high recurrence rates (up to 44%) 3, 1
• Failure to culture the abscess may lead to ineffective antibiotic selection if needed
• Antibiotics alone without adequate drainage will not resolve the infection 1
• Overlooking underlying conditions that may predispose to abscess formation

Recent evidence from a meta-analysis of 2,406 participants demonstrated that the addition of systemic antibiotics to incision and drainage resulted in improved clinical cure rates (OR 2.32) and decreased incidence of new lesions compared to placebo 5, challenging earlier studies that showed no benefit.