What is the appropriate management for a chronic pustule (abscess or boil) present for 3 years?

Management of a Chronic Pustule Present for 3 Years

A pustule persisting for 3 years is not a typical acute abscess or furuncle and requires incision and drainage to establish diagnosis, followed by evaluation for underlying causes such as pilonidal cyst, hidradenitis suppurativa, foreign material, or epidermoid cyst. 1

Initial Diagnostic Approach

The chronicity of this lesion fundamentally changes the differential diagnosis from typical acute skin infections:

• A recurrent abscess at the same site mandates searching for local causes including pilonidal cyst, hidradenitis suppurativa, foreign material, or epidermoid cyst 1
• Epidermoid cysts contain skin flora in keratinous material, and inflammation occurs as a reaction to cyst wall rupture rather than primary infection 1, 2
• True chronic abscesses lasting years are extremely rare and suggest an underlying structural problem 1

Primary Treatment: Incision and Drainage

Incision and drainage is the definitive treatment for this lesion regardless of the underlying cause 1, 2:

• Perform thorough evacuation of pus and probe the cavity to break up loculations 1, 2
• Simply cover the surgical site with a dry dressing—this is usually the most effective approach 1, 2
• Packing with gauze causes more pain without improving healing compared to sterile gauze coverage alone 1

Role of Antibiotics

Antibiotics are NOT routinely indicated for this chronic lesion 2:

• Simple abscesses and epidermoid cysts do not require antibiotics after adequate drainage 2
• Gram stain and culture of inflamed epidermoid cysts are specifically NOT recommended 1
• Antibiotics should only be added if systemic signs are present (fever >38°C, tachycardia >90 bpm, tachypnea >24 breaths/min, WBC >12,000 or <4,000) 1
• If MRSA coverage is needed due to systemic illness, use clindamycin, doxycycline, or TMP-SMX 1

Critical Next Steps After Drainage

Culture the lesion during drainage to guide any necessary antibiotic therapy and identify unusual pathogens 1:

• Recurrent abscesses should be cultured early in the course 1
• If S. aureus is isolated and lesions recur, consider a 5-10 day antibiotic course active against the pathogen 1

Evaluate for hidradenitis suppurativa if the lesion is in axillary, inguinal, or perianal regions 1:

• Hidradenitis presents with recurrent painful nodules and abscesses in intertriginous areas 1
• Management includes intralesional corticosteroids for acute flares, antiseptic washes, and consideration of systemic therapies for chronic disease 1

Common Pitfalls to Avoid

• Do not attempt needle aspiration—this fails in 75% of cases overall and >90% with MRSA 1
• Do not prescribe antibiotics without drainage—this will not resolve a chronic collection 2
• Do not assume this is a simple infection—3 years of persistence demands investigation for underlying structural causes 1
• Do not ignore the possibility of foreign material—retained foreign bodies can cause chronic draining lesions 1

Special Consideration: Adult-Onset Recurrent Abscesses

• Adults developing recurrent abscesses do NOT need evaluation for neutrophil disorders unless abscesses began in early childhood 1
• For recurrent S. aureus infections, consider decolonization with intranasal mupirocin twice daily for 5 days, daily chlorhexidine washes, and decontamination of personal items 1, 3