What is the recommended treatment for a boil?

Treatment of Boils (Furuncles)

Incision and drainage is the primary and definitive treatment for boils, with antibiotics reserved only for specific high-risk situations such as systemic signs of infection, extensive cellulitis, or immunocompromised patients. 1, 2

Initial Management Approach

Small Boils

• Apply moist heat to promote spontaneous drainage 1
• Warm compresses help bring the boil to a head, allowing natural drainage 1
• This conservative approach is satisfactory for small furuncles 1

Large Boils and All Carbuncles

• Incision and drainage is the recommended treatment 1, 2
• The procedure involves:
  • Making an incision to access the abscess 1
  • Thorough evacuation of pus 1
  • Probing the cavity to break up loculations 1
  • Covering the surgical site with a dry dressing (most effective approach) 1

Critical pitfall to avoid: Do not pack the wound with gauze—this causes more pain and does not improve healing compared to simply covering with sterile gauze 1

When to Add Antibiotics

Antibiotics are typically unnecessary after incision and drainage alone 2, but should be added when any of the following are present:

• 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, 2
• Severe or extensive disease with rapid progression 2
• Extensive surrounding cellulitis 1, 2
• Markedly impaired host defenses or immunocompromised state 1, 2
• Extremes of age 2
• Difficult to drain locations 2
• Associated septic phlebitis 2
• Lack of response to incision and drainage alone 2

Antibiotic Selection When Indicated

• Empirical coverage for community-acquired MRSA is recommended pending culture results 2
• Treatment options include:
  • Clindamycin 2
  • Trimethoprim-sulfamethoxazole (TMP-SMX) 2
  • Tetracyclines (doxycycline or minocycline) 2
  • Linezolid 2
• Duration: 5 to 10 days based on clinical response 2

Critical pitfall: Do not use rifampin as a single agent or adjunctive therapy for boils 2

Culture and Sensitivity

• Gram stain and culture of pus are recommended, but treatment without these studies is reasonable in typical cases 1, 2
• Culture recurrent abscesses early in the course of infection 2

Management of Recurrent Boils

For patients with recurrent S. aureus boils, implement a 5-day decolonization regimen 2:

• Intranasal mupirocin 2
• Daily chlorhexidine washes 1, 2
• Daily decontamination of personal items (towels, sheets, clothes) 1, 2
• Thorough laundering of clothing, towels, and bed wear 1
• Separate use of towels and washcloths 1

Investigate Underlying Causes

• Search for local causes at sites of recurrent infection: pilonidal cyst, hidradenitis suppurativa, or foreign material 1, 2
• Adult patients with recurrent abscesses beginning in early childhood should be evaluated for neutrophil disorders 1
• Risk factors for recurrence include obesity, diabetes, age <30 years, smoking, and prior antibiotic use 3

Critical Pitfalls to Avoid

• Do not attempt ultrasonographically guided needle aspiration—successful in only 25% of cases overall and <10% with MRSA infections 1, 2
• Do not routinely prescribe antibiotics without incision and drainage—antibiotics without drainage are ineffective as primary treatment 2
• Avoid home lancing with non-sterile instruments—this can lead to severe invasive infections including osteomyelitis and bacteremia 4
• Do not overuse antibiotics for uncomplicated boils that could be managed with incision and drainage alone 1