Are topical anesthetics (TAs) effective in treating cutaneous abscess with associated systemic infection?

Topical Anesthetics Are Not Effective for Cutaneous Abscesses with Systemic Infection

Topical anesthetics are not effective for cutaneous abscesses with associated systemic infection, and incision and drainage with appropriate systemic antibiotics is the recommended treatment approach. 1

Management of Cutaneous Abscesses with Systemic Infection

Primary Treatment: Incision and Drainage

• Incision and drainage (I&D) remains the cornerstone of treatment for cutaneous abscesses, regardless of whether systemic infection is present 1
• For complex abscesses with systemic infection, surgical drainage should be performed promptly to prevent progression of infection 1
• Linear incisions are most commonly used (85% of providers), with thorough evacuation of pus and breaking up of loculations 1, 2

Pain Management

• Topical anesthetics alone are insufficient for pain control during I&D of abscesses with systemic infection 2, 3
• Most providers (76%) use narcotic analgesics in addition to local anesthetic for adequate pain control 2
• Local anesthetic techniques that are more effective include:
  • Field block around the abscess (used by 60% of providers) 2
  • Local infiltration over the roof of the abscess (used by 71% of providers) 2

Antibiotic Therapy

• For cutaneous abscesses with associated systemic infection, antibiotic therapy is mandatory in addition to I&D 1
• Empiric broad-spectrum antibiotic therapy covering Gram-positive, Gram-negative, and anaerobic bacteria is recommended 1
• Systemic antibiotics are specifically indicated when:
  • Systemic signs of infection are present 1
  • Source control is incomplete 1
  • Significant cellulitis surrounds the abscess 1
  • Patient is immunocompromised 1
  • Multiple lesions are present 1
  • Cutaneous gangrene is present 1

MRSA Considerations

• If MRSA is suspected, appropriate antibiotic coverage should be provided 1
• Options for MRSA coverage include glycopeptides (e.g., vancomycin) and newer antimicrobials 1
• For outpatient treatment of MRSA, options include clindamycin, TMP-SMX, tetracyclines, or linezolid 1

Limitations of Topical Anesthetics in Abscesses with Systemic Infection

• Topical anesthetics have limited penetration into inflamed tissue and cannot reach adequate depth in abscess cavities 3
• Systemic infection alters local pH, which can reduce the efficacy of topical anesthetics 3
• The inflammatory process in systemic infection creates a hostile environment for topical anesthetic action 3
• Topical anesthetics are more appropriate for superficial procedures rather than deep-seated infections with systemic involvement 3

Follow-up Care

• Follow-up is typically recommended at 48 hours after I&D unless the wound is concerning and requires closer evaluation 2
• Wound packing is commonly used (91% of providers) though evidence for this practice is limited 2
• Wound cultures are not routinely needed (only 32% of providers routinely obtain them) unless there is concern for unusual pathogens or treatment failure 2

Special Considerations

• In patients with darkly pigmented skin, diagnosis may be challenging as erythema can be difficult to appreciate 4
• Complex abscesses (perianal, perirectal, or at injection sites) require special attention and more aggressive management when systemic infection is present 1
• Alternative techniques such as aspiration followed by anesthetic injection into the cavity may be considered for specific locations like sacrococcygeal abscesses, but these are not standard for abscesses with systemic infection 5