Management of Boils (Furuncles) in Pediatric Patients
Incision and drainage is the primary and definitive treatment for boils in children, and antibiotics should NOT be routinely used for simple boils. 1
Primary Treatment Approach
Perform incision and drainage for all large furuncles and carbuncles as this is the recommended definitive treatment. 1 The procedure should be performed by adequately trained personnel to minimize complications. 1
When Antibiotics Are NOT Needed
- Simple boils that are drained do not require antibiotic therapy. 1
- Most furuncles rupture and drain spontaneously or following moist heat application, and systemic antimicrobials are unnecessary in these cases. 1
When Antibiotics ARE Indicated
Add antibiotics active against Staphylococcus aureus (including MRSA coverage) only when the child exhibits:
- Systemic inflammatory response syndrome (SIRS) including temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or white blood cell count >12,000 or <4,000 cells/µL 1
- Markedly impaired host defenses (immunocompromised patients) 1
- Multiple lesions or carbuncles 1
- Fever or evidence of systemic infection 1
Microbiological Evaluation
- Obtain Gram stain and culture of pus from carbuncles and abscesses, though treatment without these studies is reasonable in typical cases 1
- Blood cultures should be performed if systemic infection is suspected 1
Critical Safety Warning
Never allow parents or caregivers to lance boils at home with needles or other instruments. 2 A case report documented severe invasive methicillin-sensitive Staphylococcus aureus (MSSA) infection with osteomyelitis, subperiosteal abscess, and pyomyositis in a 10-year-old boy after his mother lanced a neck boil with a hot needle. 2
Management of Recurrent Boils
If a child develops recurrent boils:
- Culture the abscess early in the course to guide antibiotic selection 1
- Search for local causes such as pilonidal cyst, hidradenitis suppurativa, or foreign material at sites of recurrent infection 1
- Consider a 5-day decolonization regimen including twice-daily intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items (towels, sheets, clothes) for recurrent S. aureus infections 1
- Evaluate for neutrophil disorders if recurrent abscesses began in early childhood 1
- Treat with a 5- to 10-day course of antibiotic active against the cultured pathogen 1
Alternative Drainage Methods to Avoid
Do not use ultrasonographically guided needle aspiration as an alternative to incision and drainage. 1 A randomized trial showed aspiration was successful in only 25% of cases overall and less than 10% with MRSA infections. 1
Wound Management After Drainage
- Simply cover the surgical site with a dry sterile dressing as this is usually the easiest and most effective treatment 1
- Avoid routine wound packing as one study found packing caused more pain without improving healing compared to just covering with sterile gauze 1
Risk Factors to Consider
Children at higher risk for recurrent boils include those with obesity, diabetes, young age (<30 years), and recent antibiotic use within 6 months. 3 Approximately 10% of patients develop a repeat boil within 12 months. 3