Treatment of Boils (Furuncles)
Incision and drainage is the primary treatment for boils, with antibiotics serving as adjunctive therapy only in specific circumstances. 1
Primary Management Approach
- Incision and drainage alone is adequate for simple boils or furuncles 1
- Systemic antibiotics are usually unnecessary unless there are specific complications 1
When to Add Antibiotics
Antibiotics should be added to incision and drainage in the following situations:
- Severe or extensive disease involving multiple sites 1
- Rapid progression with associated cellulitis 1
- Signs and symptoms of systemic illness (fever, tachycardia, etc.) 1
- Immunocompromised patients 1
- Extremes of age 1
- Boils in difficult-to-drain areas (face, hands, genitalia) 1
- Associated septic phlebitis 1
- Lack of response to incision and drainage alone 1
- Markedly impaired host defenses 1
Antibiotic Selection for Outpatient Treatment
When antibiotics are indicated, options include:
- Clindamycin (300-450 mg PO three times daily): Effective against Staphylococcus aureus (including MRSA) and streptococci 2, 3
- Trimethoprim-sulfamethoxazole (TMP-SMX) (1-2 double-strength tablets twice daily): Effective against MRSA but has limited activity against β-hemolytic streptococci 1
- Doxycycline or minocycline (100 mg twice daily): Effective against MRSA but with limited activity against streptococci; not recommended for pregnant women or children under 8 years 1
- Linezolid (600 mg twice daily): Effective against MRSA and streptococci, but more expensive than other options 1
Treatment Duration
- 5-10 days of antibiotic therapy is typically recommended when antibiotics are indicated 1
- Treatment should be individualized based on clinical response 1
Management of Recurrent Boils
For patients with recurrent boils:
- Search for local causes such as pilonidal cysts or hidradenitis suppurativa 1
- Drain and culture recurrent abscesses early in the course of infection 1
- Consider a 5-day decolonization regimen with:
- Intranasal mupirocin twice daily
- Daily chlorhexidine washes
- Daily decontamination of personal items (towels, sheets, clothes) 1
- Risk factors for recurrence include obesity, diabetes, smoking, age <30 years, and prior antibiotic use 4
Common Pitfalls to Avoid
- Delaying drainage of the abscess can result in treatment failure regardless of antibiotic choice 2
- Unnecessary use of antibiotics for simple boils that can be adequately treated with incision and drainage alone 1
- Failure to identify and address risk factors for recurrent boils, such as obesity and diabetes 4
- Not considering MRSA as a potential pathogen, especially in community-acquired infections 5
Special Considerations
- Carbuncles (coalescent inflammatory mass with pus draining from multiple follicular orifices) typically require incision and drainage 1
- For large furuncles and all carbuncles, incision and drainage is the recommended treatment 1
- Gram stain and culture of pus from carbuncles and abscesses are recommended, but treatment without these studies is reasonable in typical cases 1