When to place xerogel in an abscess?

When to Place Xeroform (Iodoform Gauze) in Abscess Cavities

Based on the highest quality evidence, you should NOT routinely place xeroform or any packing material in abscess cavities after incision and drainage, as current guidelines demonstrate no benefit to healing time, recurrence rates, or fistula prevention, while causing significant additional pain and healthcare costs. 1

The Evidence Against Routine Packing

The 2021 World Journal of Emergency Surgery (WSES-AAST) guidelines explicitly state that no recommendation can be made regarding the use of packing after drainage of an anorectal abscess based on available literature. 1 This represents the most authoritative position on this topic.

Key Supporting Data:

• A Cochrane review found the evidence so weak (only 64 patients in two high-bias studies) that authors concluded it is "unclear whether using internal dressings influences time to healing, wound pain, development of fistulae, or abscess recurrence." 1

• A subsequent multi-center observational study of 141 patients definitively concluded that packing is costly, painful, and does not add benefit to the healing process. 1

• The evidence shows packing causes significant pain during dressing changes without therapeutic benefit. 2

When Packing MAY Be Considered (Limited Indications)

While the evidence argues against routine use, traditional practice suggests packing only for:

Hemostasis Purposes Only

• Immediate post-operative bleeding control in the operating room 1
• Remove within 24 hours and do not continue serial packing 2

Prevention of Premature Skin Closure

• Some practitioners place initial packing to prevent skin edges from closing before the cavity heals from within 1
• However, this can be achieved through other means (see alternatives below)

Recommended Alternative Approach

Instead of xeroform packing, use one of these evidence-based alternatives:

Primary Recommendation:

• Allow the wound to heal by secondary intention without any packing 2
• Instruct patients to begin warm water soaks 24-48 hours after drainage 2
• Keep wound clean and ensure skin edges don't close prematurely 2

Alternative Drainage Method:

• Place a simple catheter or drain into the abscess cavity that drains into an external dressing 1
• Leave in place until drainage stops 1
• This avoids painful dressing changes while maintaining drainage 1

Critical Clinical Pearls

Factors That Actually Matter for Outcomes:

The recurrence rate after abscess drainage can reach 44%, but this is driven by: 1, 3

• Inadequate initial drainage (most important factor)
• Loculations not broken up during initial procedure
• Horseshoe-type abscess anatomy
• Delayed time from disease onset to incision

Complete and adequate drainage at the initial procedure is far more important than any packing strategy. 1

Special Considerations for Anorectal Abscesses:

For perianal/perirectal abscesses specifically:

• Make the incision as close to the anal verge as possible to minimize potential fistula length 1
• Examine for associated fistula tracts during drainage 3
• If low subcutaneous fistula found, perform fistulotomy at time of drainage 1
• If sphincter-involving fistula found, place a loose draining seton instead 1, 3
• Do NOT probe for fistulas if not obvious - this causes iatrogenic complications 1, 4

Common Pitfalls to Avoid

1. Don't pack routinely "because we've always done it" - the evidence doesn't support this practice 1, 2

2. Don't prescribe antibiotics routinely after adequate drainage - they're only indicated for: 1, 4

   • Presence of sepsis or systemic infection
   • Immunocompromised patients
   • Significant surrounding cellulitis
   • Incomplete source control

3. Don't allow premature skin closure - ensure the cavity heals from inside out, but this doesn't require packing 2

4. Don't underestimate the importance of complete initial drainage - this is the single most important factor in preventing recurrence, not the packing strategy 1, 3

Patient Instructions for Unpacked Wounds

• Remove any initial hemostatic packing within 24 hours 2
• Begin warm water soaks 24-48 hours post-procedure 2
• Return immediately for fever >38.5°C, spreading redness, or worsening pain after initial improvement 2
• Expect 15-44% recurrence rate even with optimal management 2

Note: The research on xerogel materials 5, 6, 7 pertains to advanced wound dressing technology for chronic wounds, not abscess management, and should not influence your decision-making for acute abscess drainage.