What is the treatment for infected painful lipomas?

Treatment of Infected Painful Lipomas

Infected lipomas require urgent surgical excision combined with broad-spectrum antibiotics targeting Staphylococcus aureus and Streptococcus species, as these are the most common pathogens in soft tissue infections following lipoma manipulation or spontaneous infection. 1

Immediate Management

Clinical Assessment

• Evaluate for necrotizing soft tissue infection (NSTI), which can occur even after minor skin breaches and represents a life-threatening complication requiring emergency intervention 1
• Look for signs of systemic infection: fever, tachycardia, hypotension, and signs of septic shock 1
• Examine for local signs: extensive erythema, bullae formation, crepitus, rapid progression of symptoms, and disabling pain disproportionate to physical findings 1

Antibiotic Therapy

• Initiate empiric broad-spectrum antibiotics immediately covering Staphylococcus aureus, Streptococcus group A, Streptococcus pyogenes, and anaerobic organisms 1
• Consider flucloxacillin or gentamicin as first-line agents for soft tissue infections in this context 1
• Continue antibiotics for 5-6 days minimum, adjusting based on culture results and clinical response 1

Definitive Treatment

Surgical Intervention

• Complete en bloc surgical excision is the standard treatment for infected lipomas, providing both source control and definitive management 2, 3
• Marginal resections as complete en bloc specimens provide excellent rates of long-term local control 2
• If NSTI is suspected or confirmed, urgent extensive debridement is life-saving and takes priority over cosmetic concerns 1
• Multiple debridement procedures may be necessary for successful treatment of necrotizing infections 1

Surgical Planning

• Plan the excision so that any contaminated tissue tract can be safely removed during the procedure 4
• In cases of deep-seated or large lipomas with infection, consider preoperative imaging (MRI or ultrasound) to assess extent of involvement 2, 4

Special Considerations

Red Flags Requiring ICU-Level Care

• Septic shock requiring vasopressor support 1
• Acute renal failure 1
• Respiratory compromise requiring mechanical ventilation 1
• Rapidly progressive soft tissue necrosis 1

Distinguishing Simple Infection from NSTI

• NSTI presents with disproportionate pain, rapid progression (often within 24-48 hours), systemic toxicity, and bullae formation 1
• Early recognition is critical as mortality increases dramatically with delayed treatment 1
• When in doubt, proceed with surgical exploration rather than observation 1

Post-Treatment Management

Wound Care

• Consider negative pressure wound therapy systems for extensive debridement sites 1
• Flap advancement and skin grafting may be necessary for reconstruction after extensive debridement 1
• Monitor for recurrence, though properly excised lipomas have low recurrence rates 2

Follow-up

• Following surgical excision and post-operative wound care, patients can be discharged to primary care once infection is resolved 2
• Re-referral is only necessary if there is clinical suspicion of recurrence 2

Common Pitfalls to Avoid

• Do not delay surgical intervention in favor of prolonged antibiotic therapy alone—infected lipomas require source control 1
• Do not underestimate the severity of soft tissue infections in lipomas; necrotizing infections can develop even after minor procedures 1
• Avoid incomplete excision, which increases recurrence risk 2
• Do not rely on physical examination alone; imaging helps assess extent of infection and involvement of surrounding structures 4, 5