Management of Furuncles
For small furuncles, apply moist heat to promote spontaneous drainage; for large furuncles and all carbuncles, perform incision and drainage—systemic antibiotics are unnecessary unless fever, extensive cellulitis, or systemic signs are present. 1, 2
Initial Treatment Based on Size
Small Furuncles
- Apply moist heat to promote spontaneous drainage 3, 1, 4
- This conservative approach is satisfactory for lesions without fluctuance 3
- No antibiotics are needed for uncomplicated small furuncles 1, 2
Large Furuncles and All Carbuncles
- Incision and drainage is the definitive treatment 1, 2, 4
- Make an incision over the fluctuant area, thoroughly evacuate pus, and probe the cavity to break up loculations 2
- After drainage, cover the surgical site with a dry dressing—packing with gauze is not necessary and may cause more pain without improving healing 1, 2
When to Add Systemic Antibiotics
Antibiotics are usually unnecessary after adequate drainage, but add them when any of these conditions are present 1, 2:
- Fever or systemic inflammatory response syndrome (SIRS)
- Extensive surrounding cellulitis
- Markedly impaired host defenses (immunosuppression, diabetes)
- Multiple lesions
- Evidence of systemic infection
Antibiotic Selection When Indicated
- Choose an agent active against Staphylococcus aureus 1
- For methicillin-susceptible S. aureus (MSSA): oral penicillinase-resistant penicillins (dicloxacillin 250 mg every 6 hours for severe infections) or first-generation cephalosporins 2, 5
- For suspected MRSA (high-prevalence areas or risk factors present): doxycycline, clindamycin, or trimethoprim-sulfamethoxazole 1, 2
- Continue therapy for at least 48 hours after the patient becomes afebrile and asymptomatic 5
Management of Recurrent Furunculosis
Decolonization Strategies
- Apply intranasal mupirocin ointment twice daily for the first 5 days each month—this reduces recurrences by approximately 50% 3, 1, 4
- Daily chlorhexidine washes are also effective in reducing recurrences 1, 2, 4
- For patients with susceptible S. aureus, oral clindamycin 150 mg daily for 3 months decreases subsequent infections by approximately 80% 3
Environmental and Hygiene Measures
- Bathe with antibacterial soaps such as chlorhexidine 3, 1
- Thoroughly launder clothing, towels, and bed linens 3, 1, 4
- Use separate towels and washcloths to prevent transmission 3, 1, 4
- Daily decontamination of personal items 2
- Evaluate and treat colonized family members or close contacts, as outbreaks can occur in settings involving close personal contact 3, 6
Important Clinical Pitfalls
- Avoid antibiotic overuse for simple furuncles that have been adequately drained—this contributes to antimicrobial resistance 2
- Do not confuse furuncles with hidradenitis suppurativa, which requires different management 2
- Needle aspiration has low success rates and is not recommended 2
- Culture is not routinely needed for typical, isolated furuncles, but obtain cultures in recurrent cases or treatment failures 2
- Evaluate for underlying predisposing factors in recurrent cases, particularly nasal colonization with S. aureus (present in 20-40% of the general population) 3, 1