When should the wound be packed after incision and drainage of an abscess?

Wound Packing After Incision and Drainage: Evidence-Based Recommendations

Direct Answer

You should not pack wounds after incision and drainage of simple abscesses, as packing provides no proven benefit while causing significantly more pain and healthcare costs without improving healing time or reducing recurrence rates. 1, 2

Evidence Against Routine Packing

The highest quality evidence comes from the 2022 PPAC2 multicenter randomized controlled trial of 433 patients, which definitively demonstrated that:

• Non-packing resulted in significantly lower pain scores (28.2 vs 38.2 on a 100-point scale, mean difference 9.9 points; P < 0.0001) 2
• Fistula formation rates were similar between groups (11% non-packed vs 15% packed, OR 0.69, P = 0.20) 2
• Abscess recurrence rates were low in both groups (6% non-packed vs 3% packed, OR 1.85, P = 0.20) 2

The World Society of Emergency Surgery 2021 guidelines explicitly state that no recommendation can be made supporting the use of packing after drainage of an anorectal abscess based on available literature, noting that packing is costly, painful, and does not add benefit to the healing process 1

Alternative Management Strategies

Preferred Approach: No Packing with External Dressing

• Cover the wound with a simple sterile absorbent dressing only 3, 4
• Keep the wound clean and dry for the first 24-48 hours 4
• Begin warm water soaks or sitz baths at 24-48 hours post-procedure to promote continued drainage 3, 4
• Change external dressing regularly as it becomes saturated 4

Alternative: Loop Drain Technique

• Place a catheter or drain into the abscess cavity that drains into an external dressing 1, 4
• Leave in place until drainage ceases 1, 4
• This eliminates repetitive painful packing changes while maintaining drainage 4

When Packing Might Be Considered (Rare Exceptions)

If packing is used despite the evidence against it, remove it within 24 hours and do not repack 3

The only scenario where brief packing may have theoretical benefit is for immediate hemostasis in highly vascular areas, but even this should be removed within 24 hours 1, 3

Critical Pitfalls to Avoid

• Inadequate initial drainage is the primary risk factor for recurrence (15-44% recurrence rate), not absence of packing 3, 5
• Ensure all loculations are broken up during the initial drainage procedure 4
• Avoid premature skin closure that prevents inside-out healing 4
• Do not probe for fistulas in acute settings to avoid iatrogenic complications 1

Antibiotic Indications (Not Routinely Needed)

Antibiotics are indicated only when:

• Fever >38.5°C (101.3°F) persisting after drainage 3, 4
• Diabetes or immunosuppression present 3, 4
• Surrounding cellulitis extending beyond immediate abscess area 3, 4
• Signs of systemic inflammatory response or sepsis 4

Simple abscesses after adequate drainage do not require antibiotics 4

Supporting Research Evidence

Multiple studies confirm the non-packing approach:

• A 2013 pediatric study of 85 patients found no difference in recurrence rates (one recurrence in each group) between packed and non-packed groups 6
• A 2016 Cochrane review concluded it is unclear whether packing influences healing time, wound pain, fistula development, or abscess recurrence 7
• A 2012 pediatric emergency department trial showed similar failure rates (70% packed vs 59% non-packed needing intervention, difference 11%, 95% CI -15% to 36%) 8

Warning Signs Requiring Immediate Return

Patients should return immediately if they develop:

• Fever >38.5°C (101.3°F) 3, 4
• Rapidly spreading redness around the wound 3, 4
• Increasing pain, swelling, or pus after initial improvement 3, 4