What is the treatment for a large facial abscess?

Treatment of Large Facial Abscess

Incision and drainage is the primary treatment for a large facial abscess, with antibiotics added for surrounding cellulitis >5 cm, systemic signs of infection, or immunocompromised status. 1, 2, 3

Primary Treatment: Incision and Drainage

• Perform incision and drainage as first-line treatment for all facial abscesses, regardless of size 1, 2, 3
• Make a surgically appropriate incision that allows adequate drainage without injuring important facial structures (nerves, vessels) 4
• Thoroughly evacuate all pus and probe the cavity to break up loculations 1
• For wounds >5 cm, consider packing to reduce recurrence and complications 5
• Simply covering with a dry dressing is usually most effective for smaller wounds 1

When to Add Antibiotics

Add systemic antibiotics if ANY of the following are present:

• Surrounding erythema >5 cm extending beyond the abscess margins 2, 3
• Systemic signs of infection: fever >38°C, heart rate >90 bpm, or other SIRS criteria 2, 3
• Immunocompromised status: diabetes, HIV/AIDS, or immunosuppressive medications 2, 3
• Incomplete drainage or inability to adequately drain the abscess 2
• Facial location warrants a lower threshold for antibiotic therapy compared to other body sites 3

Do NOT routinely prescribe antibiotics for simple abscesses after adequate drainage in immunocompetent patients without the above features 1, 2, 3, 6

Antibiotic Selection (When Indicated)

First-line oral options for MRSA coverage:

• Trimethoprim-sulfamethoxazole: 1-2 double-strength tablets (160/800 mg) twice daily 2, 3, 7
• Doxycycline: 100 mg twice daily 2, 3
• Clindamycin: 300-450 mg three times daily 2, 3

Duration: 5-10 days, adjusted based on clinical response 2

For hospitalized patients requiring IV therapy: Vancomycin for MRSA coverage 3

Microbiological Considerations

• Culture the abscess if the patient has recurrent abscesses, fails to respond to treatment, or has risk factors for MRSA 2, 3
• Facial abscesses are typically polymicrobial, containing normal skin flora combined with organisms from adjacent mucous membranes 1
• Staphylococcus aureus is present as a single pathogen in only ~25% of cutaneous abscesses 1
• Community-acquired MRSA is increasingly common and grew in 44.3% of skin abscesses in recent trials 7

Follow-Up and Reassessment

• Reassess within 48-72 hours if no clinical improvement occurs 2, 3
• Lack of improvement may indicate inadequate drainage, resistant organisms, or deeper infection requiring surgical consultation 2, 3
• Treatment effect is greatest with history of MRSA infection, fever, and positive MRSA culture 7

Critical Pitfalls to Avoid

• Do not rely on antibiotics alone without adequate drainage—this is the most common error 1, 5, 6
• Avoid routine antibiotic prescribing for simple drained abscesses, as this contributes to antibiotic resistance without improving outcomes 3, 6
• Do not perform inadequate incisions—ensure the opening is large enough for complete drainage and prevents reaccumulation 4
• Be cautious of deeper extension into facial planes or potential complications like cavernous sinus thrombosis in the "danger triangle" of the face 4