What is the recommended treatment for small skin abscesses?

Treatment of Small Skin Abscesses

Incision and drainage is the primary recommended treatment for small skin abscesses, with antibiotics generally unnecessary unless specific risk factors are present. 1

Primary Treatment Approach

• Incision and drainage (I&D) is the cornerstone of treatment for small skin abscesses and is considered sufficient therapy for most uncomplicated cases 1
• For very small furuncles (boils), application of moist heat may help promote spontaneous drainage and could be sufficient for resolution 1
• Wound packing after I&D is commonly practiced but has not been shown to improve outcomes and may cause more pain 1, 2
• Simply covering the surgical site with a dry dressing is usually adequate for post-procedure wound care 1

When to Consider Antibiotics

Antibiotics should be added to I&D in the following situations:

• Presence of systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or abnormal white blood cell count 1
• Markedly impaired host defenses or immunocompromised patients 1
• Significant surrounding cellulitis extending beyond the abscess borders 1
• Abscess size >5 cm (associated with higher risk of treatment failure) 3, 4
• Incomplete source control after drainage 1
• High-risk locations (face, hands, genitalia) 1

Antibiotic Selection When Indicated

• If MRSA is suspected or prevalent in the community, appropriate options include:

  • Trimethoprim-sulfamethoxazole (TMP-SMX) 1, 5, 4
  • Clindamycin 1, 5
  • Doxycycline or minocycline (not for children <8 years) 1
  • Linezolid (typically reserved for more severe cases) 1

• For non-MRSA infections where streptococci are suspected:

  • Beta-lactams (penicillinase-resistant penicillins or first-generation cephalosporins) 1
  • Duration of therapy is typically 5-10 days when antibiotics are indicated 1

Special Considerations

• Recurrent abscesses require additional management:

  • Search for local causes (pilonidal cyst, hidradenitis suppurativa, foreign material) 1
  • Culture and drain early in the course of infection 1
  • Consider a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and decontamination of personal items for recurrent S. aureus infections 1
  • Evaluate for neutrophil disorders if recurrent abscesses began in early childhood 1

• Cultures are not routinely needed for typical small abscesses but should be obtained in:

  • Recurrent infections 1
  • Treatment failures 1
  • Patients with immunocompromise 1
  • Severe or atypical presentations 1

Evidence on Antibiotic Use

Recent evidence suggests antibiotics may provide some benefit even for smaller abscesses:

• A 2017 randomized controlled trial found that adding TMP-SMX or clindamycin to I&D improved short-term outcomes compared to I&D alone, particularly for S. aureus infections 5
• Antibiotics may reduce the formation of new lesions in the short term 5, 6
• For MRSA abscesses specifically, a 10-day course of antibiotics showed lower failure and recurrence rates compared to shorter courses 6

However, the high cure rates with I&D alone (approximately 70-85%) must be weighed against the potential adverse effects of antibiotics 5, 2.

Common Pitfalls to Avoid

• Failing to perform adequate I&D (the most important therapeutic intervention) 1
• Prescribing antibiotics unnecessarily for simple, small abscesses without risk factors 1, 2
• Not considering MRSA coverage when antibiotics are indicated in areas with high MRSA prevalence 1
• Overlooking underlying conditions that may predispose to recurrent abscesses 1
• Inadequate follow-up for patients with risk factors for treatment failure 6