What are the guidelines for treating boils on the buttocks?

Management of Boils on the Buttocks

Incision and drainage is the primary treatment for boils on the buttocks, with antibiotics reserved only for specific high-risk situations such as severe/extensive disease, rapid progression with cellulitis, systemic illness, immunosuppression, or failure of drainage alone. 1

Primary Treatment Approach

Incision and Drainage

• Perform incision and drainage for all furuncles (boils) and carbuncles on the buttocks as the definitive treatment. 1, 2
• The procedure must be aggressive enough to ensure complete evacuation of pus and probing of the cavity to break up any loculations. 1, 2
• Simply cover the surgical site with a dry sterile dressing after drainage—this is more effective and less painful than packing the wound with gauze. 2
• For small boils in otherwise healthy patients, incision and drainage alone achieves an 85-90% cure rate without antibiotics. 3

Conservative Management for Small Boils

• For small furuncles that have not yet formed a drainable abscess, apply warm, moist compresses several times daily to promote spontaneous drainage. 2, 3
• This approach is particularly appropriate for children and may avoid the need for surgical intervention. 3

When to Add Antibiotic Therapy

Add antibiotics to incision and drainage only when specific high-risk features are present: 1

• Severe or extensive disease (multiple boils or large carbuncles)
• Rapid progression with associated cellulitis extending beyond the immediate area
• Signs of systemic illness (fever >38°C, tachycardia >90 bpm, tachypnea >24 breaths/min)
• Comorbidities such as diabetes or immunosuppression
• Extremes of age (very young or elderly)
• Difficult drainage locations (such as perianal area on the buttocks)
• Associated septic phlebitis
• Lack of response to incision and drainage alone after 48-72 hours

Critical Pitfall to Avoid

• Never use antibiotics alone without drainage for drainable abscesses—this leads to treatment failure. 1, 2

Antibiotic Selection When Indicated

First-Line Oral Options (for CA-MRSA coverage)

Choose one of the following regimens for 5-10 days based on clinical response: 1

• Clindamycin 300-450 mg three times daily (avoid if local resistance >10%)
• Trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily
• Doxycycline 100 mg twice daily (avoid in children <8 years) 3

When to Hospitalize

Admit for intravenous antibiotics when: 1

• Systemic toxicity persists despite appropriate oral antibiotics

• Rapidly progressive or worsening infection despite drainage

• Associated septic phlebitis

• Inability to achieve adequate source control with outpatient drainage

• Use vancomycin 15-20 mg/kg IV every 8-12 hours for hospitalized patients with confirmed or suspected MRSA. 1

Prevention of Recurrent Boils

For patients with repeated boils on the buttocks, implement a 5-day decolonization regimen: 1

• Intranasal mupirocin ointment twice daily for 5 days (reduces recurrence by ~50%) 3
• Daily chlorhexidine body washes
• Daily decontamination and thorough laundering of personal items (towels, sheets, clothing, underwear) 1, 2
• Use separate towels and washcloths 2, 3

Risk Factors for Recurrence

• Obesity, diabetes, smoking, and prior antibiotic use within 6 months are all independently associated with recurrent boils. 4
• Approximately 10% of patients develop a repeat boil within 12 months. 4
• Friction from tight clothing (particularly underwear or pants) may contribute to boil development on the buttocks, especially in obese individuals. 5

Special Considerations for Buttock Location

• Evaluate for underlying conditions if boils recur at the same site on the buttocks: pilonidal cyst, hidradenitis suppurativa, or retained foreign material. 2
• The perianal location on the buttocks represents a "difficult drainage location" that warrants consideration of adjunctive antibiotic therapy even after successful drainage. 1
• Friction and pressure from sitting may contribute to boil formation on the buttocks, particularly in obese patients—advise patients to avoid tight-fitting clothing and prolonged sitting when possible. 5

What NOT to Do

• Do not use rifampin as monotherapy or adjunctive therapy—resistance develops rapidly with no proven benefit. 1
• Do not attempt needle aspiration alone—it has only a 25% success rate overall and <10% with MRSA infections. 2
• Do not pack the wound with gauze—this causes more pain without improving healing compared to simple dry dressing coverage. 2