Treatment of Pimple Abscess
Incision and drainage is the primary and most important treatment for a pimple abscess, and antibiotics are generally unnecessary for simple cases without systemic signs of infection. 1, 2
Primary Treatment: Incision and Drainage
- All cutaneous abscesses, regardless of size, should be drained as this is the definitive therapy and the most critical intervention. 1, 2
- Thorough evacuation of pus and probing the cavity to break up loculations is essential for successful drainage. 2
- For larger abscesses (>5 cm), use multiple counter-incisions rather than a single long incision to prevent step-off deformity and delayed wound healing. 2
- Simply covering the surgical site with a dry dressing is usually effective, though some clinicians pack larger wounds (>5 cm) with gauze to potentially reduce recurrence. 2, 3
- Do not attempt needle aspiration as it has a low success rate of 25% and <10% with MRSA infections. 2, 4
When Antibiotics Are NOT Needed
For simple abscesses in immunocompetent patients, antibiotics are unnecessary after adequate drainage. 1, 2, 5
- Skip antibiotics if the patient has:
When Antibiotics ARE Indicated
Add antibiotics to drainage when any of the following are present:
Systemic Signs of Infection (SIRS Criteria)
- Temperature >38°C or <36°C 1
- Tachycardia >90 beats/minute 1
- Tachypnea >24 breaths/minute 1
- White blood cell count >12,000 or <400 cells/µL 1
Local Factors
- Significant surrounding cellulitis extending >5 cm from the drainage site 2
- Incomplete source control after drainage 2
- Complex locations (perianal, perirectal, axillary) 2, 6
- Multiloculated abscess 6
Patient Factors
Antibiotic Selection When Indicated
For Simple Abscesses (Trunk/Extremities)
- First-line: Clindamycin 300-450 mg PO every 6-8 hours for 7-10 days (cure rate 83.1%, superior to other options) 2, 7
- Alternative: TMP-SMX (though clindamycin has higher cure rates and lower recurrence) 2, 7
- Alternative for penicillin allergy: Cephalexin 500 mg every 6 hours 2
For Complex Abscesses (Axillary/Perineal)
- Clindamycin 600-900 mg IV every 8 hours PLUS ciprofloxacin 400 mg IV every 12 hours for broad polymicrobial coverage 2
- Alternative: Cephalexin 500 mg every 6 hours plus metronidazole 500 mg every 8 hours 2
- For axillary location specifically: Cefoxitin or ampicillin-sulbactam due to mixed flora 2
Duration
- Treat for 4-7 days based on clinical response 2
- Immunocompromised or critically ill patients may require up to 7 days 2
MRSA Coverage Considerations
- An antibiotic active against MRSA is recommended for patients with carbuncles, abscesses with SIRS, or markedly impaired host defenses. 1
- Clindamycin provides excellent MRSA coverage and has the added benefit of reducing recurrence (6.8% vs 13.5% with TMP-SMX). 7
- MRSA presence decreases success rates of both drainage and antibiotic therapy. 4
For Recurrent Abscesses
- Culture the abscess and treat with a 5-10 day course of an antibiotic active against the isolated pathogen. 1
- Consider a 5-day decolonization regimen: intranasal mupirocin twice daily, daily chlorhexidine washes, and daily decontamination of personal items. 1, 2
- Search for local causes such as pilonidal cyst, hidradenitis suppurativa, or foreign material. 1
Critical Pitfalls to Avoid
- Do not delay drainage while waiting for laboratory results - drainage is the priority therapeutic intervention. 2
- Do not treat abscesses with antibiotics alone without drainage - this leads to treatment failure regardless of antibiotic choice. 2, 6
- Do not routinely culture simple abscesses in immunocompetent patients, as antibiotics are not needed. 5
- Do not use metronidazole as monotherapy - it lacks activity against S. aureus and streptococci, the primary pathogens. 2
- Assuming all abscesses need antibiotics contributes to antimicrobial resistance. 6