Treatment of Boils and Abscesses
Incision and drainage is the primary and definitive treatment for boils (furuncles), carbuncles, and abscesses, with antibiotics reserved only for specific high-risk situations. 1
Primary Treatment Approach
Perform incision and drainage for all large furuncles, carbuncles, and abscesses as this is the cornerstone of management with strong, high-quality evidence supporting this approach. 1
Post-Drainage Wound Management
- Simply cover the surgical site with a dry sterile dressing rather than packing the wound, as packing causes more pain without improving healing outcomes. 1
- Avoid needle aspiration as it has only 25% success rate overall and less than 10% success with MRSA infections. 1
When to Add Antibiotics
Antibiotics are NOT routinely needed after incision and drainage. 1 However, add antibiotics directed against S. aureus (including MRSA coverage) in these specific situations:
Systemic Signs (SIRS Criteria Present)
- Temperature >38°C or <36°C 1
- Tachypnea >24 breaths per minute 1
- Tachycardia >90 beats per minute 1
- White blood cell count >12,000 or <4,000 cells/µL 1
High-Risk Patient Factors
- Markedly impaired host defenses (immunocompromised state, diabetes, HIV, chronic steroid use, chemotherapy) 1
- Extensive surrounding cellulitis beyond the abscess borders 1
- Incomplete source control after drainage 1
Antibiotic Selection When Indicated
For MRSA Coverage (Most Community-Acquired Cases)
- Oral options: Trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily, doxycycline 100 mg twice daily, or clindamycin 300-450 mg three times daily 1
- IV options for severe cases: Vancomycin 15-20 mg/kg every 8-12 hours (target trough 15-20 mcg/mL) 2
Duration
- 5-10 days for patients requiring antibiotics 1
- Shorter courses (4 days) acceptable if source control is adequate in immunocompetent patients 3
Culture Recommendations
- Obtain Gram stain and culture from carbuncles and abscesses (though treatment without cultures is reasonable in typical cases) 1
- Do NOT culture inflamed epidermoid cysts 1
- Always culture recurrent abscesses early in the course and treat based on pathogen isolated 1
Special Considerations for Underlying Conditions
Diabetes Patients
- Carbuncles develop most commonly on the back of the neck in diabetic individuals 1
- Lower threshold for antibiotic therapy given impaired host defenses 1
Recurrent Abscesses
- Search for local causes: pilonidal cyst, hidradenitis suppurativa, or foreign material at the site 1
- Consider decolonization regimen for recurrent S. aureus: intranasal mupirocin twice daily for 5 days, daily chlorhexidine washes, and daily decontamination of personal items 1
- Evaluate for neutrophil disorders only if recurrent abscesses began in early childhood 1
Common Pitfalls to Avoid
- Do not rely on antibiotics alone without drainage for abscesses—this will fail 1
- Do not routinely prescribe antibiotics for simple abscesses after adequate drainage in healthy patients 1, 4
- Do not attempt needle aspiration as the primary drainage method 1
- Do not pack wounds unless absolutely necessary, as it increases pain without benefit 1