What is the treatment for furunculosis?

Treatment of Furunculosis

Incision and drainage is the primary treatment for large furuncles and all carbuncles, while small furuncles can be managed with moist heat application several times daily to promote spontaneous drainage. 1

Initial Management Based on Lesion Size

Small Furuncles

• Apply warm, moist compresses several times daily to bring the infection to a head and facilitate natural drainage 1, 2
• This approach achieves an 85-90% cure rate with drainage alone, regardless of antibiotic use 2
• Most small furuncles rupture and drain spontaneously or following moist heat treatment 1

Large Furuncles and Carbuncles

• Perform incision and drainage for all large furuncles and carbuncles 1, 3
• Simply cover the surgical site with a dry sterile dressing—this is usually the easiest and most effective wound treatment 1
• Avoid packing the wound with gauze, as one study found packing caused more pain without improving healing compared to just covering with sterile gauze 1
• Obtain Gram stain and culture of pus from carbuncles and abscesses, though treatment without these studies is reasonable in typical cases 1

Antibiotic Therapy Decision-Making

When Antibiotics Are NOT Needed

• Systemic antibiotics are usually unnecessary for uncomplicated furuncles in otherwise healthy patients 1, 3, 2
• Avoid antibiotics for isolated lesions without systemic signs 1

When Antibiotics ARE Indicated

Prescribe antibiotics active against S. aureus (including MRSA coverage) when any of the following are present: 1, 3

• Systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or WBC >12,000 or <4,000 cells/µL 1
• Fever or other evidence of systemic infection 1, 3
• Extensive surrounding cellulitis 3, 2
• Multiple lesions 3, 2
• Markedly impaired host defenses or immunocompromised status 1, 3

Antibiotic Selection

• Clindamycin is the preferred agent if local resistance is <10% (10-13 mg/kg/dose every 6-8 hours in children) 2
• Choose an antibiotic active against MRSA based on local susceptibility patterns 1
• Avoid tetracyclines (including doxycycline) in children under 8 years of age 3, 2

Management of Recurrent Furunculosis

Most Effective Treatment Approach

For patients with recurrent furunculosis, oral clindamycin 150 mg daily for 3 months decreases subsequent infections by approximately 80% 3, 4

Decolonization Strategy (5-Day Regimen)

Implement a comprehensive 5-day decolonization protocol: 1, 3

• Intranasal mupirocin ointment twice daily (reduces recurrences by ~50%) 3, 2
• Daily chlorhexidine washes or dilute bleach baths 3, 2
• Daily decontamination of personal items: towels, sheets, and clothes laundered in hot water 3, 2

Repeat this 5-day decolonization regimen on the first 5 days of each month 3

Critical Pitfall to Avoid

• Do not rely solely on intranasal mupirocin alone—one randomized trial in military personnel showed intranasal mupirocin by itself did not reduce MRSA skin infections 3
• The combination approach (mupirocin + chlorhexidine + environmental decontamination) is essential 3

Household Contact Management

• Culture and treat household contacts and close contacts who are colonized 3
• One study demonstrated significantly fewer recurrences when preventive measures were employed for both patient and household contacts versus patient alone 3
• Enforce strict use of separate towels and washcloths for the affected individual 3, 2

When to Investigate Further

• Evaluate for neutrophil disorders if recurrent abscesses began in early childhood 1, 3
• Search for local causes such as pilonidal cyst, hidradenitis suppurativa, or foreign material if abscesses recur at the same site 1
• Culture recurrent abscesses early and treat with a 5-10 day course of an antibiotic active against the isolated pathogen 1

Key Clinical Pearls

• The most important predisposing factor for recurrent furunculosis is S. aureus colonization in the anterior nares or perineum 3
• Inadequate personal hygiene and exposure to others with active furuncles are major risk factors, particularly in close-contact settings like sports teams 3
• Carbuncles develop most commonly on the back of the neck, especially in individuals with diabetes 1
• Do not obtain Gram stain and culture from inflamed epidermoid cysts 1