Treatment of Skin Abscesses
For a simple superficial abscess or boil, incision and drainage is the primary treatment, and antibiotics are not needed. 1
Classification of Skin Abscesses
- Skin abscesses can be classified as simple (superficial) or complex based on their characteristics 1
- Simple abscesses have induration and erythema limited to a defined area and do not extend beyond its borders 1
- Complex abscesses may involve perianal, perirectal areas, or intravenous drug injection sites and may require more aggressive management 1
Treatment Algorithm for Skin Abscesses
Simple Abscesses
- Primary treatment is incision and drainage alone 1
- Cutaneous abscesses are typically caused by bacteria representing the normal regional skin flora 1
- Staphylococcus aureus accounts for less than half of all cutaneous abscesses, with anaerobic bacteria common in perineal areas 2
- Incision should be performed using local anesthesia with appropriate surgical technique to allow adequate drainage without injuring important structures 2
- Postoperative care includes warm soaks, drains or wicks, analgesia, and close follow-up 2
Complex Abscesses
- Require incision and drainage with adjuvant antibiotic therapy 1
- Antibiotic therapy is recommended if: 1
- Systemic signs of infection are present
- Patient is immunocompromised
- Source control is incomplete
- Significant cellulitis surrounds the abscess
Antibiotic Selection for Complex Abscesses
- Empiric broad-spectrum antibiotic therapy with coverage of Gram-positive, Gram-negative, and anaerobic bacteria is recommended 1
- If MRSA is suspected, consider glycopeptides or newer antimicrobials 1
- For CA-MRSA coverage, options include trimethoprim-sulfamethoxazole (TMP-SMX), tetracyclines, or clindamycin 3, 4
Surgical Management Techniques
- A large abscess should be drained with multiple counter incisions rather than a long incision to prevent step-off deformity and delayed wound healing 1
- Ultrasonographically guided needle aspiration is insufficient therapy for skin abscesses compared to traditional incision and drainage (26% vs 80% success rate) 5
- Primary versus secondary closure after incision and drainage shows similar healing rates and treatment failure rates 6
Special Considerations
- The presence of CA-MRSA decreases the success of drainage procedures 5
- Recent research suggests antibiotics may provide benefit in some cases, but this must be weighed against the risk of antimicrobial resistance 4, 7
- For perianal and perirectal abscesses, prompt surgical drainage is essential to prevent expansion into adjacent spaces and progression to systemic infection 1
Common Pitfalls to Avoid
- Misdiagnosis by failing to differentiate between simple and complex abscesses 1
- Prescribing antibiotics for simple abscesses when not indicated 1
- Inadequate drainage leading to treatment failure or spread of infection 2
- Failure to identify a fistula tract in perianal abscesses, which may lead to recurrence 1
- Damage to adjacent structures during incision and drainage procedure 2
Remember that while recent studies suggest potential benefits of adjuvant antibiotics in some cases, the primary treatment for simple abscesses remains incision and drainage alone, with antibiotics reserved for specific indications to minimize antimicrobial resistance.