Treatment of Furuncles in Older Adults
For older adults with furuncles, incision and drainage is the primary treatment for large lesions, while small furuncles can be managed with moist heat application; systemic antibiotics are typically unnecessary unless fever, extensive cellulitis, multiple lesions, or immunocompromising conditions are present. 1
Initial Management Approach
Small Furuncles
- Apply warm, moist compresses several times daily to promote spontaneous drainage 1, 2
- This conservative approach achieves an 85-90% cure rate with drainage alone, whether or not antibiotics are used 2
- Cover the area with a dry dressing once drainage occurs 1
Large Furuncles and Carbuncles
- Perform incision and drainage for all large furuncles and carbuncles (strong recommendation, high-quality evidence) 3, 1, 4
- After drainage, cover the surgical site with a dry dressing rather than packing with gauze—packing adds unnecessary pain without improving outcomes 1, 4
When to Prescribe Antibiotics
Systemic antibiotics are not routinely needed for simple furuncles after adequate drainage 3, 1, 4. However, prescribe antibiotics active against S. aureus if any of these conditions exist: 3, 1, 4
- Fever or systemic inflammatory response syndrome (SIRS)
- Extensive surrounding cellulitis
- Multiple lesions
- Markedly impaired host defenses (immunocompromised status, diabetes, or other comorbidities common in older adults)
- Rapid progression despite drainage
- Abscess in difficult-to-drain areas (face, hand, genitalia)
Antibiotic Selection for Older Adults
When antibiotics are indicated, choose agents active against S. aureus with consideration for MRSA coverage given high community prevalence: 3, 1
Oral Options (in order of preference):
- Trimethoprim-sulfamethoxazole (TMP-SMX): 1-2 double-strength tablets PO twice daily 3
- Doxycycline: 100 mg PO twice daily 3
- Clindamycin: 300-450 mg PO three times daily (note: C. difficile risk may be higher in older adults) 3
- Cephalexin or Dicloxacillin: 500 mg PO four times daily (use only if MRSA is excluded or low prevalence) 3, 5
Important Considerations for Older Adults:
- Renal function monitoring is essential when using TMP-SMX or cephalosporins, as these drugs are substantially excreted by the kidney and older adults are more likely to have decreased renal function 6
- Dose adjustment may be necessary based on creatinine clearance 6
- Be cautious with clindamycin due to increased C. difficile risk in older populations 3
Management of Recurrent Furunculosis
If the older adult experiences recurrent episodes (≥4 per year), implement a comprehensive decolonization strategy: 1, 4
Decolonization Regimen:
- Intranasal mupirocin 2% ointment twice daily for 5 days each month (reduces recurrences by ~50%) 1, 4
- Daily chlorhexidine body washes for 5-14 days 1, 4
- Daily decontamination of personal items: thoroughly launder clothing, towels, and bedding 1, 4
- Use separate towels and washcloths 1, 4
Additional Measures:
- Culture recurrent abscesses early to identify the causative organism and guide antibiotic selection 4
- Evaluate household members for S. aureus colonization and treat carriers if ongoing transmission is suspected 4, 7
- Consider low-dose clindamycin for 3 months in refractory cases (1800-2400 mg daily for 21 days has shown 87% remission beyond 9 months) 8, 7
Common Pitfalls to Avoid
- Do not routinely prescribe antibiotics for simple furuncles after adequate drainage—this contributes to antibiotic resistance without improving outcomes 3, 1
- Do not pack wounds with gauze after incision and drainage—use dry dressings instead 1, 4
- Do not use oral penicillinase-resistant penicillins as initial therapy in serious, life-threatening infections in older adults 5
- Do not forget to assess for diabetes and immunosuppression in older adults, as these conditions lower the threshold for antibiotic therapy 3, 1
- Monitor for drug interactions, particularly with metformin if prescribing cephalexin, as cephalexin increases metformin levels by 24-34% 6