Treatment for Boils
The primary treatment for boils (furuncles) is incision and drainage, with antibiotics generally unnecessary unless there are complicating factors such as extensive surrounding cellulitis or systemic symptoms. 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 extends to involve several adjacent follicles, producing a coalescent inflammatory mass with pus draining from multiple follicular orifices, it's called a carbuncle. Carbuncles tend to develop on the back of the neck and are especially common in people with diabetes.
Treatment Algorithm
Step 1: Initial Management
- For small furuncles: Apply moist heat to promote drainage
- For larger furuncles and all carbuncles: Perform incision and drainage 1
- Make an incision
- Thoroughly evacuate the pus
- Probe the cavity to break up loculations
- Cover the surgical site with a dry dressing (some clinicians may pack it with gauze)
Step 2: Determine Need for Antibiotics
Systemic antibiotics are generally unnecessary for simple boils but should be added when any of the following are present 1:
- Extensive surrounding cellulitis
- Fever or other systemic symptoms
- Multiple lesions
- Immunosuppression or significant comorbidities
- Extremes of age (very young or elderly)
- Boil in a difficult-to-drain area (face, hand, genitalia)
- Associated septic phlebitis
- Lack of response to incision and drainage alone
Step 3: Antibiotic Selection (if needed)
For outpatient treatment of boils requiring antibiotics, options include 1:
- Clindamycin (300 mg three times daily)
- Trimethoprim-sulfamethoxazole (TMP-SMX)
- Tetracycline (doxycycline or minocycline)
- Linezolid
Duration of antibiotic therapy is typically 5-10 days 1.
Management of Recurrent Boils
Some individuals experience repeated attacks of furunculosis. Control measures include 1:
- Use of antibacterial soaps (e.g., chlorhexidine)
- Thorough laundering of clothing, towels, and bedding
- Separate use of towels and washcloths
- Eradication of staphylococcal carriage among colonized persons
Special Considerations
Risk Factors for Recurrence
Several factors increase the risk of recurrent boils 2:
- Obesity (RR 1.3)
- Diabetes (RR 1.3)
- Smoking (RR 1.3)
- Age <30 years (RR 1.2)
- Prior antibiotic use (RR 1.4)
Outbreaks
Outbreaks of furunculosis may occur in settings with close personal contact (e.g., sports teams, prisons) 1. Risk factors include:
- Inadequate personal hygiene
- Exposure to others with furuncles
- Skin injuries 3
Common Pitfalls to Avoid
- Overuse of antibiotics: Simple boils typically don't require antibiotics after proper drainage 1
- Inadequate drainage: Ensure complete evacuation of pus and breaking of loculations
- Failure to identify and address underlying risk factors: Especially important in recurrent cases
- Neglecting wound care: Proper wound care after drainage is essential
- Missing MRSA: Consider MRSA coverage when antibiotics are indicated, particularly in areas with high prevalence
Follow-up
- Re-evaluation within 48-72 hours to assess healing progress
- Consider complete excision of any underlying cyst once acute inflammation resolves
- For recurrent cases, investigate for nasal carriage of S. aureus and consider decolonization strategies
Recent evidence suggests that packing may not be necessary after incision and drainage of subcutaneous abscesses, as studies have shown equal efficacy without packing 4. This approach eliminates a painful component of therapy without compromising outcomes.