Furunculitis of the Scalp: Description and Treatment
Furunculitis of the scalp is best treated with incision and drainage for large lesions, while small furuncles may be managed with moist heat application to promote drainage. 1
Description of Furunculitis
- Furuncles (or "boils") are deep infections of the hair follicle, usually caused by Staphylococcus aureus, where suppuration extends through the dermis into the subcutaneous tissue, forming a small abscess 2, 1
- Each lesion presents as an inflammatory nodule with an overlying pustule through which hair emerges 2
- When infection involves several adjacent follicles, it produces a carbuncle - a coalescent inflammatory mass with pus draining from multiple follicular orifices 2, 1
- Carbuncles tend to develop on the back of the neck and are especially likely to occur in diabetic persons 2
- Furunculosis often tends to be recurrent and may spread among family members 3
Treatment Algorithm
Primary Management
- For small furuncles: Apply moist heat to promote spontaneous drainage 2, 1
- For larger furuncles and all carbuncles: Incision and thorough drainage is the recommended treatment 2, 1
- After drainage, simply cover the surgical site with a dry dressing rather than packing with gauze 2
- Gram stain, culture, and systemic antibiotics are rarely necessary for isolated lesions 2
When to Use Systemic Antibiotics
Systemic antibiotics should be used when any of these conditions are present:
- Extensive surrounding cellulitis 2, 1
- Fever or other evidence of systemic infection 1
- Multiple lesions 2
- Severely impaired host defenses 2
- Cutaneous gangrene 2
Management of Recurrent Furunculosis
- Evaluate for predisposing factors such as nasal colonization with S. aureus 2
- For recurrent cases with nasal colonization, apply mupirocin ointment twice daily in the anterior nares for the first 5 days each month (reduces recurrences by ~50%) 2, 1
- For persistent recurrent furunculosis, consider low-dose clindamycin (150 mg daily) for 3 months, which decreases subsequent infections by ~80% 2, 4
- Daily chlorhexidine washes may also be effective in reducing recurrences 1
Preventive Measures for Recurrent Cases
- 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
- Treat all household members who show signs of infection 4
- Focus on personal, interpersonal, and environmental hygiene to reduce the risk of contamination and recurrences 3
Important Considerations
- Consider MRSA coverage in high-prevalence areas or if risk factors are present, as MRSA is becoming more predominant in community settings 1, 5
- Diagnosis occasionally requires histologic confirmation and cannot be based solely on clinical appearance of scalp lesions 6
- Incision and drainage alone may not be sufficient in patients with multiple furuncles, and systemic antibiotics should be administered in these cases 5
- Hygienic education is an essential component of treatment for both the patient and family members 4, 7