Treatment of Recurrent Boils (Furuncles)
For recurrent furuncles, implement a combined approach of incision and drainage for active lesions plus a 5-day decolonization regimen including intranasal mupirocin twice daily, daily chlorhexidine body washes, and decontamination of personal items (towels, sheets, clothes), which reduces recurrences by approximately 50%. 1
Initial Management of Active Lesions
Drainage Procedures
- Perform incision and drainage for all large furuncles and carbuncles (strong recommendation, high-quality evidence). 1
- Small furuncles may be treated with moist heat application to promote spontaneous drainage. 1
- After drainage, cover the wound with a dry dressing rather than packing with gauze—packing is unnecessary and adds pain without improving outcomes. 1, 2
Antibiotic Indications
- Systemic antibiotics are NOT routinely needed for simple furuncles after adequate drainage. 1
- Prescribe antibiotics active against S. aureus ONLY if any of these conditions exist: 1
- Fever or systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, heart rate >90, respiratory rate >24, or WBC >12,000 or <4,000
- Extensive surrounding cellulitis
- Multiple lesions
- Markedly impaired host defenses (immunocompromised, diabetes)
- Use MRSA-active antibiotics (such as trimethoprim-sulfamethoxazole, doxycycline, or clindamycin if local resistance <10%) when antibiotics are indicated, given high MRSA prevalence in community-acquired skin infections. 1
Management Strategy for Recurrent Disease
Evaluation for Underlying Causes
- Culture recurrent abscesses early to identify the causative organism and guide antibiotic selection. 1
- Search for local anatomic causes: pilonidal cyst, hidradenitis suppurativa, or retained foreign material. 1
- Evaluate for neutrophil disorders ONLY if recurrent abscesses began in early childhood (not needed for adult-onset disease). 1
Decolonization Protocol
Offer decolonization when: 1
- Patient experiences recurrent SSTI despite optimizing wound care and hygiene measures
- Ongoing transmission occurs among household members or close contacts
The decolonization regimen includes: 1
- Intranasal mupirocin 2% ointment twice daily for 5 days (this can be repeated monthly for up to 1 year, reducing recurrences by ~50%)
- Daily chlorhexidine body washes for 5-14 days OR dilute bleach baths (1 teaspoon per gallon of water or ¼ cup per ¼ tub, for 15 minutes twice weekly for 3 months)
- Daily decontamination of personal items: thoroughly launder towels, sheets, and clothing with hot water
Hygiene and Environmental Measures
- Cover all draining wounds and infected skin. 1
- Avoid sharing personal items (towels, razors, clothing). 1
- Use separate towels and washcloths for affected individuals. 1
- Clean surfaces that contact bare skin daily with commercial cleaners or detergents. 1
Important Caveats
Limitations of Decolonization
- Screening cultures before decolonization are NOT routinely recommended if at least one prior infection was documented as MRSA. 1
- Surveillance cultures after decolonization are NOT routinely recommended in the absence of active infection. 1
- The optimal frequency and duration of decolonization therapy remain unclear, and there is theoretical concern about selecting for resistant organisms with repeated use. 1
Risk Factors for Recurrence
- Approximately 10% of patients develop repeat boils within 12 months. 3
- Independent risk factors include: obesity, diabetes, age <30 years, smoking, and prior antibiotic use within 6 months. 3
- Nasal colonization with S. aureus (present in 20-40% of the general population) is the primary identifiable predisposing factor for most individuals with recurrent disease. 1