Management of Recurrent Axillary Boils
For recurrent axillary boils (furuncles/abscesses), perform incision and drainage for each recurrence, search for underlying causes like hidradenitis suppurativa, and implement a decolonization protocol with intranasal mupirocin twice daily plus daily chlorhexidine washes for 5 days if S. aureus is cultured. 1
Initial Evaluation and Acute Management
Rule Out Underlying Structural Causes
- Search specifically for hidradenitis suppurativa, pilonidal cysts, or foreign material at the recurrence site 1
- Hidradenitis suppurativa is a chronic inflammatory condition affecting apocrine gland-bearing areas (axillae, groin) that can mimic recurrent boils but requires different long-term management 2
Acute Treatment of Each Episode
- Perform incision and drainage early in the course of infection 1
- Obtain culture from the abscess drainage 1
- Administer a 5-10 day course of antibiotics active against the cultured pathogen (typically MRSA-active agents in the current era) 1
- Systemic antibiotics are particularly indicated if SIRS is present (fever >38°C, tachycardia >90 bpm, tachypnea >24 breaths/min, or WBC >12,000 or <4,000 cells/µL) 1
Prevention of Recurrences
Decolonization Protocol
Implement a 5-day decolonization regimen including: 1
- Intranasal mupirocin twice daily
- Daily chlorhexidine body washes (or dilute bleach baths: 1/4-1/2 cup per full bath) 1
- Daily decontamination of personal items (towels, sheets, clothing) 1
Important Caveats About Decolonization
The evidence for decolonization effectiveness in the MRSA era is mixed. Older trials showed benefit with monthly intranasal mupirocin or oral clindamycin, but more recent randomized trials in military personnel found that mupirocin alone did not reduce subsequent skin infections 1. The combination approach (mupirocin plus chlorhexidine plus environmental decontamination) may be more effective, particularly when extended to household contacts 1.
Consider Household Contact Decolonization
- One study demonstrated that employing preventive measures for both the patient and household contacts resulted in significantly fewer recurrences than treating the patient alone 1
- This suggests treating close contacts simultaneously with the same decolonization protocol
Special Considerations
When to Evaluate for Neutrophil Disorders
- Evaluate for neutrophil dysfunction only if recurrent abscesses began in early childhood 1
- Adult-onset recurrent abscesses do not warrant neutrophil function testing 1
Hidradenitis Suppurativa Management
If hidradenitis suppurativa is confirmed as the underlying cause, medical management differs significantly from simple recurrent furuncles. For severe, recurrent axillary hidradenitis suppurativa refractory to medical therapy, wide surgical excision with reconstruction may be necessary, with fasciocutaneous flaps showing the lowest recurrence rates (10%) compared to primary closure (48%) 2.
Antibiotic Selection
- For MRSA coverage (common in community-acquired skin infections), use vancomycin, linezolid, daptomycin, or oral agents like trimethoprim-sulfamethoxazole or doxycycline 1
- Base antibiotic choice on culture results when available 1
Common Pitfalls to Avoid
- Do not use the term "cellulitis" for purulent collections - this is inappropriate terminology and leads to incorrect treatment (antibiotics alone rather than drainage) 1
- Do not rely on antibiotics alone without drainage - incision and drainage is the primary treatment 1
- Do not assume decolonization will work with mupirocin alone - the combination approach with chlorhexidine and environmental decontamination appears more effective 1
- Do not miss hidradenitis suppurativa - this requires different long-term management and may need dermatology or surgical referral 1, 2