When should packing be removed after incision and drainage (I&D) of a cutaneous abscess, including simple, perianal, pilonidal, or postoperative cavities?

When to Remove Packing from Abscess

Primary Recommendation

Packing should be removed within 24 hours if it was placed, but the preferred approach is to avoid packing altogether and use only an external absorbent dressing. 1, 2

Evidence-Based Rationale

Packing Provides No Clinical Benefit

• Multiple high-quality guidelines demonstrate that packing adds pain and healthcare costs without improving healing time, reducing recurrence rates, or preventing fistula formation. 3, 2
• The World Society of Emergency Surgery (WSES) 2021 guidelines explicitly state that "no recommendation can be made regarding the use of packing after drainage of an anorectal abscess" based on available literature, and a multicenter observational study of 141 patients concluded packing is "costly and painful and does not add benefit to the healing process." 3
• A Cochrane review of randomized controlled trials found it is "unclear whether using internal dressings (packing) influences time to healing, wound pain, development of fistulae, abscess recurrence, or other outcomes." 4

Specific Timing for Removal

• If packing has already been placed for hemostasis, remove it within 24 hours and transition to external dressing only. 1, 2
• Prolonged packing beyond initial hemostasis offers no additional therapeutic advantage. 2

Preferred Alternative Management

Instead of Traditional Packing

• Use a catheter or drain placed into the abscess cavity that drains to an external dressing, leaving it in place until drainage ceases. 3, 2
• This minimally invasive approach eliminates the need for repetitive painful packing changes while maintaining adequate drainage. 2, 5

Post-Drainage Wound Care Protocol

• Keep the wound clean and dry for the first 24-48 hours. 1, 2
• Begin warm water soaks or sitz baths at 24-48 hours post-procedure to promote drainage and healing. 1, 2, 5
• Allow healing by secondary intention (from the inside out) and do not allow skin edges to close prematurely. 1, 2
• Change external absorbent dressings regularly as they become saturated. 5

Critical Pitfalls to Avoid

The Real Risk Factor for Recurrence

• Inadequate initial drainage—not the absence of packing—is the primary risk factor for recurrence (15-44% recurrence rate). 1, 2
• Key recurrence risk factors include incomplete drainage, loculated collections not adequately broken up, and premature skin closure preventing drainage from inside out. 5

Special Considerations

• For anorectal abscesses, up to one-third may have an underlying fistula tract that increases recurrence risk. 3, 1
• Do not probe for fistulas unless they are clinically evident, as unnecessary probing can cause iatrogenic injury. 3, 2

Exception: When Packing May Be Considered

• One research study suggested that packing wounds larger than 5 cm may reduce recurrence and complications. 6
• However, this contradicts higher-quality guideline evidence and should be weighed against the established lack of benefit and increased pain. 3, 2

Antibiotic Considerations (Not Routinely Needed)

• Antibiotics are not routinely required after adequate drainage unless high-risk features are present: 2, 5
  • Fever >38.5°C (101.3°F) 1, 2
  • Erythema extending >5 cm beyond wound margins 2
  • Diabetes, immunosuppression, or surrounding cellulitis 1, 5
  • Signs of systemic inflammatory response or sepsis 5

Warning Signs Requiring Return

• Fever >38.5°C (101.3°F) 1, 5
• Rapidly spreading redness around the wound 1
• Increasing pain, swelling, or pus after initial improvement 1, 5