What is the recommended treatment and prescription for furunculosis (boil infection)?

Treatment of Furunculosis (Boil Infection)

The primary treatment for furunculosis is incision and drainage for large furuncles and carbuncles, while small furuncles may be effectively managed with moist heat application to promote spontaneous drainage. 1

Initial Management Based on Furuncle Size

• Small furuncles: Apply moist heat to promote spontaneous drainage 2
• Large furuncles and all carbuncles: Perform incision and drainage (strong evidence) 2, 1
• After drainage, cover the surgical site with a dry dressing rather than packing with gauze 2

Antibiotic Therapy

• Systemic antibiotics are usually unnecessary for uncomplicated furuncles that have been adequately drained 2, 1

• Antibiotics should be prescribed only if the following conditions are present:

  • Extensive surrounding cellulitis 2, 1
  • Fever or other evidence of systemic infection 2
  • Multiple lesions 2, 1
  • Severely impaired host defenses 2
  • Systemic inflammatory response syndrome (SIRS) 1

• When antibiotics are indicated, choose an agent active against Staphylococcus aureus, considering MRSA coverage in high-prevalence areas 1

Management of Recurrent Furunculosis

Recurrent furunculosis (defined as ≥4 episodes/year) requires a more aggressive approach 3:

• Evaluate for predisposing factors such as nasal colonization with S. aureus 2, 1

• Implement decolonization strategies:

  • Intranasal mupirocin ointment twice daily for 5 days each month (reduces recurrences by ~50%) 2, 1
  • Daily chlorhexidine washes 1, 3
  • For persistent cases, oral clindamycin 150 mg daily for 3 months is highly effective (decreases subsequent infections by ~80%) 2, 4

• The CMC regimen has shown 87% remission beyond 9 months in difficult cases 3:

  • Skin disinfection with chlorhexidine for 21 days
  • Nasal mupirocin ointment for 5 days
  • Oral clindamycin 1800-2400 mg for 21 days

Prevention of Recurrence and Outbreak Control

• Improve personal hygiene with antibacterial soaps such as chlorhexidine 2, 1
• Thoroughly launder clothing, towels, and bedding 2, 1
• Use separate towels and washcloths 2, 1
• Screen and treat family members or close contacts who may be carriers 4, 5, 3
• Avoid contact with contaminated skin and fomites 6

Important Considerations

• Furunculosis outbreaks can occur in settings with close personal contact (e.g., prisons, sports teams) 2
• Inadequate personal hygiene and exposure to others with furuncles are important predisposing factors 2
• Approximately 20-40% of the general population has nasal colonization with S. aureus, which is a major risk factor for recurrent disease 2
• Recurrent cases may require extended treatment and follow-up to ensure complete resolution 5, 3