What is the recommended management for recurrent skin or soft‑tissue abscesses?

Management of Recurrent Skin and Soft Tissue Abscesses

For recurrent abscesses, incision and drainage remains the cornerstone of treatment, followed by a 5–10 day course of antibiotics active against the cultured pathogen, and consideration of a 5-day decolonization regimen using twice-daily intranasal mupirocin plus daily chlorhexidine washes for recurrent S. aureus infections. 1

Initial Evaluation and Drainage

Search for underlying local causes at the site of recurrence, including pilonidal cysts, hidradenitis suppurativa, or retained foreign material, as eradicating these can be curative. 1

• Drain all recurrent abscesses early in the course of infection and obtain cultures to guide antibiotic selection. 1
• Use multiple counter-incisions for large abscesses rather than a single long incision to prevent step-off deformity and optimize drainage. 2
• Thoroughly evacuate pus and probe the cavity to break up loculations. 2

Antibiotic Therapy for Recurrent Abscesses

Culture-directed treatment is essential. After obtaining cultures, initiate a 5–10 day course of antibiotics active against the isolated pathogen. 1

When to Use Antibiotics After Drainage

Antibiotics are indicated when any of the following are present: 1, 2

• Temperature >38.5°C
• Heart rate >110 beats/min or signs of SIRS
• White blood cell count >12,000 cells/µL
• Erythema extending >5 cm from the wound margin
• Immunocompromised status or significant comorbidities (diabetes, obesity, cancer)
• Complex locations (perianal, perirectal, axillary, or injection drug use sites)
• Incomplete source control

Antibiotic Selection

For simple recurrent abscesses: Clindamycin 300–450 mg PO every 6–8 hours is superior to other oral agents, with an 83% cure rate. 2 Alternative options include TMP-SMX 160/800 mg (one double-strength tablet) twice daily. 2

For complex abscesses in axillary or perirectal regions: Use broader coverage such as clindamycin 600–900 mg IV every 8 hours plus ciprofloxacin 400 mg IV every 12 hours, or cephalexin plus metronidazole for mixed aerobic-anaerobic flora. 2

For injection drug users: Empiric broad-spectrum coverage is recommended due to polymicrobial flora, including MRSA, Gram-negatives, and anaerobes. 1, 3

Decolonization Strategy for Recurrent S. aureus Infections

Consider a 5-day decolonization regimen for patients with recurrent S. aureus abscesses, though efficacy data in the MRSA era are limited. 1

The regimen includes: 1

• Intranasal mupirocin applied twice daily for 5 days
• Daily chlorhexidine body washes (or dilute bleach baths: ¼–½ cup bleach per full bath)
• Daily decontamination of personal items including towels, sheets, and clothing

Important caveat: A randomized trial in military personnel showed that nasal mupirocin alone did not reduce subsequent MRSA skin infections, and chlorhexidine-impregnated cloth scrubbing three times weekly was also ineffective. 1 The combined 5-day intensive regimen may be more effective, though data remain sparse. 1

Household Contact Decolonization

One pediatric study demonstrated that employing preventive measures for both the patient and household contacts resulted in significantly fewer recurrences compared to treating the patient alone. 1 Consider extending decolonization efforts to close contacts in cases of repeated failures.

Addressing Predisposing Factors

Examine and treat underlying conditions that promote recurrence: 1

• Lower extremity cellulitis/abscesses: Carefully examine interdigital toe spaces for fissuring, scaling, or maceration; treating tinea pedis eradicates colonization and reduces recurrence risk. 1
• Edema management: Elevation of affected areas, compression stockings, pneumatic pressure pumps, or diuretic therapy as appropriate. 1
• Skin barrier maintenance: Keep skin well-hydrated with emollients to prevent dryness and cracking. 1
• Underlying cutaneous disorders: Treat conditions such as venous eczema or stasis dermatitis. 1

Special Populations

Evaluate for neutrophil disorders in adult patients whose recurrent abscesses began in early childhood, as neutrophil dysfunction causes recurrent abscesses starting in childhood. 1

Immunocompromised patients (malignancy on chemotherapy, severe cell-mediated immunodeficiency, HIV) require blood cultures and broader antimicrobial coverage. 1

Duration of Therapy

The recommended duration is 5–10 days based on clinical response and resolution of inflammation. 1, 2 Extend treatment if infection has not improved within this period. 1

• Immunocompromised or critically ill patients may require up to 7 days. 2
• Patients with ongoing signs of infection beyond 7 days warrant diagnostic re-evaluation. 2

Common Pitfalls to Avoid

Do not rely on antibiotics alone without drainage. Even with elevated inflammatory markers, source control through drainage is essential. 2

Do not use metronidazole as monotherapy for skin abscesses, as it lacks activity against S. aureus and streptococci; use only in combination regimens for polymicrobial infections. 2

Do not delay drainage while awaiting laboratory results. Drainage is the priority therapeutic intervention. 2

Avoid needle aspiration for abscesses, as it has a low success rate of 25% and <10% with MRSA infections. 2

For abscesses >5 cm: More aggressive management is required, as initial ineffective antibiotic therapy without adequate drainage predicts hospitalization. 2, 4