Furuncle Treatment in Healthy Adults
For small furuncles, apply moist heat to promote spontaneous drainage; for large furuncles, perform incision and drainage—systemic antibiotics are unnecessary unless fever, extensive cellulitis, multiple lesions, or immunocompromising conditions are present. 1, 2
Initial Management Based on Lesion Size
Small furuncles:
- Apply warm, moist compresses several times daily to promote spontaneous drainage 3, 1
- Once drainage occurs, cover with a dry dressing 1, 4
- This conservative approach is satisfactory for uncomplicated small lesions 3
Large furuncles:
- Incision and drainage is the primary treatment (strong recommendation, high-quality evidence) 1, 2, 4
- Cure rate is 85-90% with drainage alone, regardless of antibiotic use 4
- After drainage, cover the surgical site with a dry dressing rather than packing with gauze—packing adds unnecessary pain without improving outcomes 1, 2, 4
- Gram stain and culture are rarely necessary for simple cases 3
When to Use Systemic Antibiotics
Antibiotics are NOT routinely needed after adequate drainage 1, 2, 4
Prescribe antibiotics ONLY when any of these conditions exist: 1, 2, 4
- Fever or systemic inflammatory response syndrome (SIRS)
- Extensive surrounding cellulitis
- Multiple lesions
- Markedly impaired host defenses (immunocompromised, diabetes)
- Cutaneous gangrene
- Severe systemic manifestations
Antibiotic selection when indicated:
- Choose agents active against Staphylococcus aureus 1, 4
- Consider MRSA coverage given high community prevalence 1, 2, 4
- Oral options include: trimethoprim-sulfamethoxazole, doxycycline, clindamycin, cephalexin, or dicloxacillin 2, 4
Management of Recurrent Furunculosis
Predisposing factors to evaluate:
- Nasal colonization with S. aureus is present in 20-40% of the general population and is the primary identifiable risk factor for recurrent disease 3, 2
- Inadequate personal hygiene and exposure to others with furuncles 3
- Evaluate household members for S. aureus colonization if ongoing transmission is suspected 2, 4
Decolonization strategy (offer when recurrent SSTI persists despite optimizing hygiene): 2
- Intranasal mupirocin 2% ointment twice daily in the anterior nares for the first 5 days each month—reduces recurrences by approximately 50% 3, 1, 2
- Daily chlorhexidine body washes for 5-14 days 1, 2, 4
- Daily decontamination of personal items (towels, sheets, clothes) 1, 2, 4
- Alternative for highly recurrent cases: Oral clindamycin 150 mg daily for 3 months decreases subsequent infections by approximately 80% (for susceptible S. aureus) 3
Hygiene measures to prevent transmission: 3, 1
- Bathe with antibacterial soaps such as chlorhexidine
- Thoroughly launder clothing, towels, and bed linens
- Use separate towels and washcloths
- Cover all draining wounds and infected skin 2
- Clean surfaces that contact bare skin daily with commercial cleaners 2
Important Caveats
- Screening cultures before decolonization are NOT routinely recommended if at least one prior infection was documented as MRSA 2
- Surveillance cultures after decolonization are NOT routinely recommended in the absence of active infection 2
- Culture recurrent abscesses early to identify the causative organism and guide antibiotic selection 2, 4
- Evaluate for local anatomic causes in recurrent cases: pilonidal cyst, hidradenitis suppurativa, or retained foreign material 2
- Outbreaks may occur in settings involving close personal contact (families, prisons, sports teams) where skin injury is common 3