What is the best course of treatment for a large pimple (furuncle) on the forehead that has increased in size to that of a golf ball after attempting to pop it and using warm compresses?

Management of Large Forehead Furuncle

The large, golf ball-sized lesion on the forehead requires immediate incision and drainage as the primary treatment. 1

Assessment and Initial Management

This presentation is consistent with a furuncle (boil) that has progressed to a larger abscess after attempted manipulation. When furuncles reach this size, especially after unsuccessful drainage attempts, they require proper medical intervention:

• Size and location: A golf ball-sized lesion on the forehead represents a severe furuncle or possibly a carbuncle (coalescence of multiple furuncles)
• Failed home treatment: Warm compresses and attempted self-drainage have worsened the condition
• Danger zone: The forehead is in the "danger triangle" of the face, where infections can potentially spread to intracranial structures

Treatment Algorithm

Step 1: Incision and Drainage (I&D)

• Incision and drainage is the definitive treatment for large furuncles 1
• The procedure involves:
  • Proper sterile technique
  • Making an adequate incision
  • Complete evacuation of purulent material
  • Breaking up loculations within the abscess cavity
  • Simple coverage with sterile gauze (packing is generally not necessary and may cause more pain) 1

Step 2: Determine Need for Antibiotics

Systemic antibiotics are generally not required for typical furuncles after I&D unless any of these factors are present 1:

• Fever or other systemic symptoms (SIRS)
• Extensive surrounding cellulitis
• Location in a high-risk area (face/head)
• Immunocompromised status
• Multiple lesions

Given the location and size of this lesion, an antibiotic active against Staphylococcus aureus (including MRSA coverage) is warranted:

• Options include:
  • Trimethoprim-sulfamethoxazole (TMP-SMX)
  • Doxycycline
  • Clindamycin

Step 3: Culture Consideration

• Obtain culture of the purulent material to guide antibiotic therapy, especially important given the size and location 1

Step 4: Follow-up Care

• Daily wound care with gentle cleaning and sterile dressing changes
• Follow-up in 48-72 hours to assess healing
• Complete the full course of antibiotics if prescribed

Prevention of Recurrence

If this is a recurrent issue, consider:

1. Decolonization regimen for S. aureus:

   • Intranasal mupirocin twice daily for 5 days
   • Daily chlorhexidine washes
   • Daily decontamination of personal items (towels, sheets, clothes) 1

2. Evaluation for underlying conditions if recurrent abscesses are present:

   • Diabetes
   • Immunodeficiency
   • Poor hygiene practices

Common Pitfalls to Avoid

• Inadequate drainage: Ensure complete evacuation of purulent material
• Antibiotic overuse: Not all furuncles require antibiotics after proper I&D
• Neglecting culture: Important for large or recurrent lesions to guide therapy
• Ignoring systemic symptoms: Fever, chills, or malaise may indicate spreading infection requiring more aggressive treatment
• Delayed follow-up: The facial location warrants close monitoring due to risk of spread

This large forehead lesion requires prompt medical attention due to its size, location, and failure of home treatment. Proper incision and drainage with consideration of antibiotics is the standard of care for optimal outcomes.