What is the management of a skin boil?

Management of Skin Boils

Incision and drainage is the primary treatment for boils (furuncles) and carbuncles, with antibiotics generally not needed for simple, uncomplicated cases. 1, 2

Understanding Boils

• Boils (furuncles) are infections of hair follicles, usually caused by Staphylococcus aureus, where infection extends through the dermis into subcutaneous tissue, forming a small abscess 1, 2
• Carbuncles develop when infection involves several adjacent follicles, producing a coalescent inflammatory mass with pus draining from multiple follicular orifices, commonly on the back of the neck, especially in individuals with diabetes 1, 2

Treatment Approach Based on Severity

For Simple Boils

• For small furuncles, application of moist heat is satisfactory and may promote spontaneous drainage 1, 2
• Warm compresses help bring the boil to a head, allowing it to drain naturally 2

For Larger Boils and All Carbuncles

• Incision and drainage is the definitive treatment 1, 2
• The procedure involves:
  • Making an incision to access the abscess 2
  • Thorough evacuation of pus 1, 2
  • Probing the cavity to break up loculations 1, 2
  • Simply covering the surgical site with a dry dressing (most effective wound treatment) 1, 2

Post-Drainage Care

• Gram stain, culture, and systemic antibiotics are rarely necessary for uncomplicated boils 1
• Simply covering the surgical site with a dry dressing is usually the easiest and most effective treatment of the wound 1, 2

When to Consider Antibiotics

Antibiotics should be added to incision and drainage in the following situations:

• Presence of systemic inflammatory response syndrome (SIRS) 1, 2
• Markedly impaired host defenses 1, 2
• Extensive surrounding cellulitis 1, 2
• Severe systemic manifestations of infection, such as high fever 1, 2
• Immunocompromised patients 3

Management of Recurrent Boils

• Daily chlorhexidine washes to reduce bacterial colonization 2
• Thorough laundering of clothing, towels, and bed wear 1, 2
• Separate use of towels and washcloths 1, 2
• Daily decontamination of personal items such as towels, sheets, and clothes 2

Special Considerations

• For recurrent abscesses at the same site, search for local causes such as a pilonidal cyst, hidradenitis suppurativa, or foreign material 2
• Adult patients with recurrent abscesses that began in early childhood should be evaluated for neutrophil disorders 2
• Outbreaks of furunculosis may occur in families and other settings involving close personal contact, especially when skin injury is common 1

Common Pitfalls to Avoid

• Packing the wound with gauze causes more pain and does not improve healing compared to simply covering the incision site with sterile gauze 2
• Ultrasonographically guided needle aspiration has been shown to be successful in only 25% of cases overall and <10% with MRSA infections, and is therefore not recommended 2
• Overuse of antibiotics for uncomplicated boils that could be managed with incision and drainage alone 1, 2
• Suturing the wound closed after drainage (may lead to recurrence) 1

Antibiotic Selection (When Indicated)

• Empiric therapy should cover Staphylococcus aureus, including consideration for MRSA in high-risk patients 1, 3
• Consider empiric coverage for CA-MRSA in patients who don't respond to first-line therapy 1