From the Guidelines
Incision and drainage (I&D) is the primary treatment for simple abscesses or boils, and it should be performed by first obtaining informed consent and administering appropriate anesthesia (local, regional, or procedural sedation) 1. The procedure involves several key steps:
- Cleaning the area with antiseptic solution such as chlorhexidine or povidone-iodine
- Making an incision with a #11 blade directly over the fluctuant area, ensuring the cut is large enough to allow adequate drainage but minimizing cosmetic impact
- Expressing all purulent material by applying gentle pressure around the wound edges
- Breaking up any loculations using a hemostat or finger to ensure complete drainage
- Irrigating the cavity with sterile saline until clear Some important considerations include:
- The incision should follow skin tension lines when possible
- For simple abscesses, packing is generally no longer recommended as it increases pain without improving outcomes
- For complex or recurrent abscesses, consider placing a small wick or drain
- Apply a sterile dressing and provide clear wound care instructions including daily dressing changes and warm compresses
- Prescribe appropriate pain medication and consider antibiotics only for specific indications such as systemic illness, immunocompromise, or abscesses in high-risk areas
- Schedule follow-up within 48-72 hours to assess healing This procedure is effective because it removes the collection of purulent material that serves as a focus of infection and allows the body's natural healing processes to resolve the infection, as supported by the most recent guidelines 1.
From the Research
Steps for Incision and Drainage (I&D)
- The process of I&D typically involves making a surgically appropriate incision to allow adequate drainage without injuring important structures 2.
- Local anesthesia is generally used for the incision, with intraoperative and postoperative systemic analgesia also considered 2.
- Postoperative care includes warm soaks, drains or wicks, analgesia, and close follow-up 2.
- The decision to use antibiotics is typically reserved for selected cases, such as sepsis or systemically unwell patients, or when there is significant cellulitis 2, 3, 4.
- Wound culture and antibiotics do not necessarily improve healing, but packing wounds larger than 5 cm may reduce recurrence and complications 5.
- The use of packing is still a topic of debate, with some studies suggesting that it may not be necessary and can even increase post-operative pain 6, 3.
Considerations for I&D
- The size and location of the abscess can impact the decision to pack the wound or use antibiotics 5, 6.
- The presence of certain high-risk features, such as immunocompromised status or positive wound cultures for MRSA, may influence the decision to use antibiotics 3.
- The use of protocols to guide and streamline patient management can help reduce variability in care, but is not universally adopted 4.