What is the treatment for an erupted abscess?

Treatment of Erupted Abscess

The primary treatment for an erupted abscess is surgical incision and drainage, with antibiotics only recommended in specific circumstances such as systemic infection, immunocompromised patients, incomplete source control, or significant surrounding cellulitis. 1

Initial Management Based on Abscess Type

• Simple superficial abscesses or boils require only incision and drainage as primary treatment, and antibiotics are generally not needed 2, 3
• Simple abscesses are characterized by induration and erythema limited to a defined area without extending beyond its borders 2
• These abscesses do not extend into deeper tissues and are not multiloculated 2
• For larger wounds (>5 cm), packing may reduce recurrence and complications 3

Surgical Drainage Procedure

• Incision should be made at the point of maximal fluctuance 4
• Care must be taken to make a surgically appropriate incision that allows adequate drainage without injuring important structures 4
• Large abscesses should be drained with multiple counter incisions rather than a single long incision to prevent delayed wound healing 1
• After drainage, the cavity should be explored to break up loculations and ensure complete drainage 1

When Antibiotics Are Indicated

• Antibiotic therapy is recommended if systemic signs of infection are present, in immunocompromised patients, if source control is incomplete, or in cases of abscess with significant cellulitis 2
• For complex abscesses (perianal, perirectal, abdominal, or at IV drug injection sites), empiric broad-spectrum antibiotic therapy with coverage of Gram-positive, Gram-negative, and anaerobic bacteria is recommended in addition to drainage 2, 1
• When indicated for skin and soft tissue infections, clindamycin can be used at a dose of 150-300 mg every 6 hours for serious infections, and 300-450 mg every 6 hours for more severe infections 5

Management of Specific Types of Abscesses

• Anorectal abscesses should be promptly drained surgically to prevent expansion into adjacent spaces and progression to systemic infection 2, 1
• The goal of surgical therapy for anorectal abscesses is to drain the abscess expeditiously, identify any fistula tract, and either proceed with primary fistulotomy or place a draining seton 1
• Small diverticular abscesses (<4-5 cm) can be treated with antibiotic therapy alone for 7 days 1
• Large diverticular abscesses require percutaneous drainage combined with antibiotic therapy for 4 days 1

Post-Procedure Care

• Postoperative care includes warm soaks, drains or wicks for larger abscesses, analgesia, and close follow-up 4
• For most simple abscesses, wound cultures and antibiotics do not improve healing 3, 6
• Patients should be instructed to return if symptoms worsen or fail to improve within 48 hours 1

Special Considerations

• Hospitalization is recommended for patients with complicated skin and soft tissue infections, including major abscesses with systemic symptoms 1
• In the presence of sepsis, severe sepsis, septic shock, immunosuppression, diabetes mellitus, or diffuse cellulitis, emergent drainage is indicated 1
• For patients with primary iliopsoas abscess (common in IV drug users), antibiotic regimens should include coverage for S. aureus 7
• For patients with secondary abscesses (those related to gastrointestinal or genitourinary causes), antibiotic regimens should be tailored for enteric bacteria 7

Common Pitfalls to Avoid

• Inadequate drainage leading to recurrence (recurrence rates can be as high as 44%) 1
• Failure to identify and address loculations or horseshoe-type abscesses, which can lead to treatment failure 1
• Delayed incision and drainage, which is associated with higher recurrence rates 1
• Misdiagnosis of entities such as mycotic aneurysms, and spread of infection due to inadequate drainage 4