Treatment of Skin Abscess Due to Ingrown Hair
Incision and drainage is the definitive treatment for a skin abscess from an ingrown hair, and antibiotics are typically unnecessary unless systemic signs of infection are present. 1
Primary Treatment: Incision and Drainage
The cornerstone of management is incision and drainage (I&D), which involves thorough evacuation of pus and probing the cavity to break up loculations. 1 This procedure alone is sufficient for most uncomplicated abscesses without requiring antibiotics. 2
Post-Procedure Wound Care
- Simply covering the surgical site with a dry sterile dressing is usually the most effective approach 1, 2
- Packing the wound with gauze causes more pain and does not improve healing compared to just covering with sterile gauze 1
Alternative for Very Small Lesions
- For very small furuncles (boils), application of moist heat may promote spontaneous drainage and could be sufficient without requiring I&D 1, 2
When to Add Antibiotics
Antibiotics should be added to I&D only when specific criteria are met—not routinely. 1
Indications for Antibiotic Therapy:
- Systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or WBC >12,000 or <4,000 cells/µL 1, 2
- Markedly impaired host defenses or immunocompromised patients 1, 2
- Extensive surrounding cellulitis beyond the abscess borders 1, 2
- Multiple lesions 1
- High-risk anatomic locations (face, hands, genitalia) 2
Antibiotic Selection (When Indicated)
For MRSA Coverage (Most Common in Community-Acquired Abscesses):
- Trimethoprim-sulfamethoxazole (TMP-SMX) 2
- Clindamycin 2
- Doxycycline or minocycline (avoid in children <8 years) 2
- Linezolid (reserved for severe cases) 2
For Non-MRSA Infections:
- Beta-lactams such as penicillinase-resistant penicillins or first-generation cephalosporins (e.g., cephalexin) 2, 3
Duration:
Culture Considerations
- Cultures are not routinely needed for typical uncomplicated abscesses 1
- Obtain cultures in: recurrent infections, treatment failures, immunocompromised patients, or severe/atypical presentations 1, 2
Management of Recurrent Abscesses
If the abscess recurs at the same site (common with ingrown hairs):
- Search for local causes such as pilonidal cyst, hidradenitis suppurativa, or retained foreign material (the ingrown hair itself) 1
- Drain and culture early in the course of recurrent infection 1
- Consider 5-day decolonization regimen for recurrent S. aureus infections: intranasal mupirocin twice daily, daily chlorhexidine washes, and decontamination of personal items (towels, sheets, clothes) 1, 2
Common Pitfalls to Avoid
- Failing to perform adequate I&D is the most common error—this is the most important therapeutic intervention, not antibiotics 2, 4
- Prescribing antibiotics without drainage—this will fail as antibiotics cannot penetrate the abscess cavity effectively 4
- Attempting needle aspiration instead of I&D—this has only 26% success rate overall and <10% success with MRSA infections 1, 5
- Not considering MRSA coverage when antibiotics are indicated in areas with high community MRSA prevalence 2
- Overlooking the underlying cause (the ingrown hair)—addressing hair removal techniques may prevent recurrence 6, 7