What is the treatment for common buttocks skin infections such as folliculitis, furuncles, and carbuncles?

Treatment of Common Buttocks Skin Infections

For folliculitis, furuncles, and carbuncles on the buttocks, incision and drainage is the primary treatment for large furuncles and all carbuncles, while small furuncles respond to moist heat application alone; systemic antibiotics are unnecessary unless fever, extensive cellulitis, or systemic signs of infection are present. 1, 2

Initial Management by Infection Type

Folliculitis

• Apply topical benzoyl peroxide as first-line nonantibiotic treatment for simple folliculitis, which is typically self-limited 3
• Use topical mupirocin or clindamycin if topical antibiotic therapy is needed 3
• Reserve oral antibiotics (cephalexin or dicloxacillin) for treatment-resistant cases only 3

Small Furuncles

• Apply warm, moist compresses several times daily to promote spontaneous drainage, which achieves an 85-90% cure rate with drainage alone 4, 2
• Simply cover the area with a dry dressing after spontaneous drainage occurs 1
• Systemic antibiotics are unnecessary for uncomplicated small furuncles in otherwise healthy patients 1, 4

Large Furuncles and Carbuncles

• Perform incision and drainage as the definitive treatment (strong recommendation, high-quality evidence) 1, 2
• Thoroughly evacuate all pus and probe the cavity to break up loculations 1
• Cover the surgical site with a dry dressing rather than packing with gauze, as one study showed packing caused more pain without improving healing 1

When to Add Systemic Antibiotics

Prescribe antibiotics only when specific high-risk features are present: 1, 2

• Temperature >38°C or <36°C
• Tachypnea >24 breaths per minute
• Tachycardia >90 beats per minute
• White blood cell count >12,000 or <4,000 cells/µL
• Extensive surrounding cellulitis
• Multiple lesions
• Markedly impaired host defenses or immunocompromised status
• Severe systemic manifestations such as high fever

Antibiotic Selection

• Choose an agent active against MRSA in high-prevalence areas or when risk factors are present 1, 5
• For adults: Clindamycin 300-450 mg every 6 hours for serious infections 6
• For children who can swallow capsules: Clindamycin 16-20 mg/kg/day divided into 3-4 doses for severe infections 6
• Avoid tetracyclines including doxycycline in children under 8 years of age 4, 5
• Alternative options include trimethoprim-sulfamethoxazole or doxycycline (in adults) for MRSA coverage 1

Management of Recurrent Infections

The most important predisposing factor for recurrent furunculosis is S. aureus colonization in the anterior nares or perineum, present in 20-40% of the general population 1, 5

Decolonization Protocol

• Apply intranasal mupirocin ointment twice daily for the first 5 days of each month, which reduces recurrences by approximately 50% 1, 4, 5
• Implement daily chlorhexidine washes 1, 5, 2
• For severe recurrent cases, consider oral clindamycin 150 mg daily for 3 months, which decreases subsequent infections by approximately 80% 5

Environmental Measures

• Thoroughly launder all clothing, towels, bed linens, and athletic gear in hot water 5, 2
• Enforce strict use of separate towels and washcloths for the affected individual 1, 5, 2
• Daily decontamination of personal items such as sheets and clothes 1, 2
• Treat household contacts who are colonized, as one study showed significantly fewer recurrences when preventive measures included both patient and household contacts 5

Culture and Diagnostic Considerations

• Obtain Gram stain and culture of pus from carbuncles and abscesses, though treatment without these studies is reasonable in typical cases 1
• Culture recurrent abscesses early in the course of infection 1
• Gram stain and culture are not recommended for inflamed epidermoid cysts 1
• S. aureus is present as a single pathogen in only approximately 25% of cutaneous abscesses; most are polymicrobial 1

Common Pitfalls to Avoid

• Do not rely solely on topical decolonization, as one randomized trial showed intranasal mupirocin alone did not reduce MRSA skin infections 5
• Do not use needle aspiration instead of incision and drainage, as it was successful in only 25% of cases overall and <10% with MRSA infections 1
• Do not prescribe antibiotics routinely for simple abscesses after adequate drainage 1
• Evaluate for underlying neutrophil disorders if recurrent abscesses began in early childhood 1, 5
• Search for local causes such as pilonidal cyst or hidradenitis suppurativa if abscesses recur at the same site 1