Skin Abscess

Aka: Skin Abscess, Furunculosis, Furuncle, Carbuncle, Skin Boil, Recurrent Skin Abscess, Soft Tissue Abscess

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II. Definitions

  1. Furuncle (Boil, Abscess)
    1. Walled-off Nodule of purulent infection forming around a Hair Follicle
    2. Firm wall with inner fluctuant core
  2. Carbuncle
    1. Coalition of Furuncles
    2. Deeper, more extensive involvement
    3. Require greater degree of Debridement

III. Pathophysiology

  1. Hair Follicle infection that spreads to deeper tissue (often begins as Folliculitis)
  2. Abscess may also form from Cellulitis, or Cellulitis may form from abscess

IV. Risk Factors

  1. Obesity
  2. Impaired Neutrophil function
  3. Corticosteroid use
  4. Diabetes Mellitus
  5. Intravenous Drug Abuse

V. Causes

  1. Staphylococcus Aureus (most common)
  2. Streptococcus species
  3. Mixed Bacterial Infection

VI. Signs

  1. Tender, erythematous Skin Mass
  2. Often spontaneously opens and drains to skin surface
  3. Distribution
    1. Occur most commonly in areas of increased friction
    2. Buttock
    3. Extremities
    4. Axilla
    5. Breast
      1. Lactating women: Associated with Mastitis
      2. Non-Lactating women: Usually subareolar
        1. Biopsy non-subareolar lesions
  4. Precautions
    1. If IV Drug Abuse is suspected, consider Bacterial Endocarditis (e.g. auscultate for cardiac murmur)

VII. Imaging: Bedside Ultrasound (Point of Care Ultrasound)

  1. Conflicting efficacy in studies
  2. Ultrasound may alter clinical management by identifying occult abscess (occurred in 50% of cases in one study)
    1. Tayal (2006) Acad Emerg Med 13(4): 384-8 [PubMed]
  3. Ultrasound is more accurate than clinical exam in one study
    1. Test Sensitivity up to 97% Test Sensitivity and 83-85% Test Specificity
    2. Gaspari (2012) Crit Ultrasound J 4(1): 5 [PubMed]
    3. Subramaniam (2016) Acad Emerg Med 23(11):1298-306 [PubMed]
  4. Ultrasound adds little to abscess diagnosis and localization in one study
    1. ED clinicians were as accurate with physical examination as with Ultrasound (87% Test Sensitivity and 71% Test Specificity)
    2. Consider in unclear presentations
      1. But Ultrasound only 77% Test Sensitivity, 64% Test Specificity in theses cases in this study
    3. Marin (2013) Acad Emerg Med 20(6): 545-53 [PubMed]

VIII. Management: Acute Episode

  1. Trial of warm compresses for small abscesses
  2. Incision and Drainage
    1. Primary, definitive, most critical step in Skin Abscess management
  3. Antibiotic indications (in addition to Incision and Drainage)
    1. Antibiotics are usually not required for an isolated abscess without Cellulitis once the lesion is incised and drained
      1. Antibiotics do not shorten course of abscess
      2. However recurrence rate may be less with Antibiotic use
        1. Talan (2016) N Engl J Med 374(9): 823-32 +PMID:26962903 [PubMed]
    2. Antibiotic indications (post-drainage)
      1. Cellulitis (see Cellulitis for Antibiotic choices)
      2. Serious comorbidity such as Diabetes Mellitus, Immunosuppression or extremes of age
      3. Multiple sites of infection
      4. Systemic symptoms
      5. Rapid progression with concurrent Cellulitis
      6. Infection involving face, hand or genitalia
      7. Associated septic phlebitis
      8. Unreliable follow-up
      9. Large abscess (e.g. 5 cm and greater, Carbuncle)
      10. Failure to improve after Incision and Drainage
    3. Antibiotics for Skin Abscess with Cellulitis (in addition to Incision and Drainage)
      1. See Cellulitis Management
      2. As noted above, Antibiotics are not needed for simple abscess without Cellulitis
      3. Agents for MRSA
        1. Trimethoprim Sulfamethoxazole (Septra, Bactrim) DS orally twice daily for 5-10 days
        2. Doxycyline 100 mg orally twice daily for 5-10 days
        3. Clindamycin 300 mg (or 450 mg if BMI>40) rally three times daily for 5-10 days
        4. Linezolid 600 mg orally twice daily for 5-10 days
        5. Vancomycin 15 mg/kg every 12 hours
      4. Agents for known MSSA
        1. Dicloxacillin 500 mg orally three to four times daily for 5-10 days
        2. Cephalexin (Keflex) 500 mg orally three to four times daily for 5-10 days
        3. Nafcillin (or Oxacillin) 1 g IV every 4 hours
        4. Cefazolin (Ancef) 1 g IV every 8 hours
      5. References
        1. (2017) Sanford Guide, Skin Abscess (accessed 1/1/2018 on IOS app)

IX. Management: Recurrent Abscess

  1. Optimize personal hygiene
    1. Regular bathing and Hand Washing with soap and water or Alcohol-based hand cleansers
  2. Reduce transmission risk
    1. Active Skin Infections should be cleaned and covered with a dry dressing at least daily (or more as needed)
    2. Avoid sharing personal items (razors, towels, wash cloths and other linens)
    3. Wash high contact surfaces (e.g. doorknobs, counters, toilet seats) with commercial cleansers
  3. Consider differential diagnosis
    1. Methicillin Resistant Staphylococcus Aureus
    2. Retained Foreign Body (or prior surgical procedure, esp. mesh)
    3. Hidradenitis Suppurativa (groin and axilla)
    4. Pyoderma Gangrenosum (groin, legs)
    5. Inflammatory Bowel Disease with enterocutaneous fistula (groin, abdominal wall)
    6. Immunodeficiency (e.g. poorly controlled Diabetes Mellitus, Phagocytosis Disorders)
  4. Mupirocin (Bactroban)
    1. Apply intranasally bid for 5 days
    2. Reduces nasal Staphylococcus Aureus carriage
  5. Antiseptic body cleansers (e.g. Hibiclens or dilute bleach bath)
    1. Hibiclens
      1. Wash completely with Hibiclens daily for 5-14 days
    2. Dilute bleach bath
      1. Dilute bleach: 1 teaspoon bleach per gallon water OR
        1. One quarter cup bleach per 20 gallons water (or 1/4 tub of water)
      2. Soak in the dilute bleach for 15 minutes twice weekly for 3 months
      3. Shower to rinse off bleach completely
      4. Make certain to rinse and dry feet before walking across carpet (and bleaching the carpet)
  6. Other measures with minimal evidence (not recommended)
    1. Systemic Antibiotic protocols (10 day course)
      1. Not generally recommended (poor efficacy, increased resistance rates)
      2. Rifampin 600 mg PO qd and
      3. Trimethoprim-Sulfamethoxazole (Bactrim, Septra) DS twice daily
      4. Clindamycin four times daily
    2. Vitamin C 1 gram per day
      1. Effective in those with impaired Neutrophil function

X. Complications

  1. Cellulitis
  2. Gangrene
  3. Necrotizing Fasciitis
  4. Hidradenitis Suppurativa
  5. Recurrent Furunculosis

XI. References

  1. Chan (2014) Crit Dec Emerg Med 28(9): 2-7
  2. Derksen in Pfenninger (1994) Procedures, p. 50-3
  3. Gilbert (2002) Sanford Guide, p. 36-37
  4. Carroll (1996) Postgrad Med 100(3):311-22 [PubMed]
  5. Stulberg (2002) Am Fam Physician 66(1):119-24 [PubMed]

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Related Studies

Ontology: carbuncle (C0007078)

Definition (MSH) An infection of cutaneous and subcutaneous tissue that consists of a cluster of boils. Commonly, the causative agent is STAPHYLOCOCCUS AUREUS. Carbuncles produce fever, leukocytosis, extreme pain, and prostration.
Concepts Disease or Syndrome (T047)
MSH D002270
SnomedCT 200602006, 156294007, 267826003, 41570003, 91374005, 416893007
English Carbuncle, Carbuncles, carbuncles (physical finding), carbuncle (diagnosis), carbuncles, Carbuncle [Disease/Finding], nos carbuncle, Carbuncle NOS (disorder), Carbuncle (morphologic abnormality), Carbuncle of skin AND/OR subcutaneous tissue (disorder), Carbuncle of skin AND/OR subcutaneous tissue, Carbuncle of skin and subcutaneous tissue, NOS, Carbuncle NOS, Carbuncle (disorder), carbuncle
Italian Favo, Foruncolo
French Anthrax (infection cutanée), Anthrax, Anthrax (dermatose)
Japanese 癰, ﾖｳ
Swedish Böld
Czech karbunkl, Karbunkl
Finnish Karbunkkeli
Russian KARBUNKUL, КАРБУНКУЛ
Spanish carbunco de la piel Y/O del tejido celular subcutáneo, carbunco cutáneo y/o subcutáneo, carbunco de la piel Y/O del tejido celular subcutáneo (trastorno), ántrax, SAI, ántrax, SAI (trastorno), Forunculosis por Staphylococcus aureus, Forunculosis Multifocal por Staphylococcus aureus, Forunculosis Multifocal, ántrax (anomalía morfológica), ántrax cutáneo y/o subcutáneo, ántrax de la piel Y/O del tejido celular subcutáneo (trastorno), ántrax de la piel Y/O del tejido celular subcutáneo, ántrax, ántrax (trastorno), Ántrax
Polish Czyrak mnogi, Czyrak gromadny, Karbunkuł
Hungarian carbunculus
Norwegian Karbunkel
Portuguese Furunculose Multifocal por Staphylococcus aureus, Furunculose por Staphylococcus aureus, Furunculose Multifocal, Carbúnculo
Dutch karbonkel, Carbunculus, Karbunkel
German Carbunculus, Karbunkel
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Furunculosis (C0016867)

Definition (NCI) A skin condition that is characterized by recurring furuncles, lesions primarily caused by staphylococcus aureus infection of the hair follicles and surrounding skin. Furunculosis occurs more frequently in persons with immune systems disorders than in the general population.
Definition (MSH) A persistent skin infection marked by the presence of furuncles, often chronic and recurrent. In humans, the causative agent is various species of STAPHYLOCOCCUS. In salmonid fish (SALMONIDS), the pathogen is AEROMONAS SALMONICIDA.
Concepts Disease or Syndrome (T047)
MSH D005667
ICD10 L02.92
SnomedCT 112650006
English Furunculoses, FURUNCULOSIS, furunculosis (diagnosis), furunculosis, Forunculosis, Furunculosis NOS, Furunculosis [Disease/Finding], forunculosis, Furunculosis, Furunculosis (morphologic abnormality)
French FURONCULOSE, Furonculose
Portuguese FURUNCULOSE, Furunculose
Spanish FORUNCULOSIS, Furunculosis, forunculosis (anomalía morfológica), forunculosis, furunculosis, Forunculosis
German FURUNKULOSE, Furunkulose
Dutch furunculose, Furunculose
Swedish Furunkulos
Japanese ｾﾂｼｭｼｮｳ, せつ多発症, せつ腫症, せつ症, せつ, フルンケル症
Czech furunkulóza, Furunkulóza
Finnish Furunkuloosi
Russian GNOINIKI VOLOSIANYKH FOLLIKULOV, FURUNKULEZ, FURUNKULY, ГНОЙНИКИ ВОЛОСЯНЫХ ФОЛЛИКУЛОВ, ФУРУНКУЛЕЗ, ФУРУНКУЛЫ
Croatian FURUNKULOZA
Polish Czyraczność
Hungarian Furunkulózis, Furunculosis
Norwegian Furunkulose
Italian Foruncolosi
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Abscess of skin AND/OR subcutaneous tissue (C0149777)

Definition (NCI) An abscess that develops in the skin and subcutaneous tissues. Causes include folliculitis, furuncle, skin injury, and bacterial infections. Signs and symptoms include the presence of a swollen, tender, and erythematous nodular lesion in the skin associated with fever and chills.
Concepts Pathologic Function (T046)
SnomedCT 200750003, 200757000, 31928004
English SKIN & SUBCUTANEOUS TISSUE ABSCES, Abscess of skin, skin abscess (physical finding), skin abscess, Abscess of skin AND/OR subcutaneous tissue, Skin & subcutaneous tissue absces, Abscesses of skin, Skin & subcutaneous tissue abscess, abscess of skin (diagnosis), abscess of skin, Abscess;skin, Boil;skin, of skin abscess, skin boil, abscess skin, skin abscesses, abscesses cutaneous, of skin abscesses, boils skin, cutaneous abscess, boil skin, boiled skin, Skin and subcutaneous tissue abscess NOS, Skin Abscess, Subcutaneous Abscess, Abscess of skin (disorder), Cutaneous abscess, Skin abscess, Abscess of skin AND/OR subcutaneous tissue (disorder), abscess; skin, skin; abscess, Abscess of skin and subcutaneous tissue, NOS
Dutch huid- en onderhuidsweefselabces NAO, huid- en subcutaan weefselabces, abcessen van de huid, abces; huid, huid; abces
French Abcès des tissus cutanés et sous-cutanés, Abcès cutanés, Abcès de la peau et du tissu sous-cutané SAI, ABCES CUTANE
German Abszesse der Haut und des Unterhautzellgewebes NNB, Abszesse der Haut, Abszess von Haut und subkutanem Gewebe, ABSZESS HAUT UND SUBKUTANES GEWEB
Italian Ascessi cutanei, Ascesso del tessuto cutaneo e sottocutaneo, Ascesso della cute e del tessuto sottocutaneo NAS, Ascesso della cute e del tessuto sottocutaneo
Portuguese Abcesso da pele, Abcesso cutâneo e subcutâneo NE, Abcesso da pele e tecido celular subcutâneo, ABCESSO DA PELE E TECIDO SUBCUTAN
Spanish Absceso de piel, Absceso de tejido subcutáneo y piel NEOM, Absceso de piel y de tejido subcutáneo, ABSCESO DE PIEL Y TEJIDO S.C, absceso cutáneo Y/O del tejido celular subcutáneo, absceso cutáneo Y/O subcutáneo, absceso de la piel Y/O del tejido celular subcutáneo (trastorno), absceso de la piel Y/O del tejido celular subcutáneo, absceso de la piel
Japanese 皮膚および皮下組織膿瘍, 皮膚および皮下組織膿瘍ＮＯＳ, 皮膚膿瘍, ﾋﾌｵﾖﾋﾞﾋｶｿｼｷﾉｳﾖｳ, ﾋﾌﾉｳﾖｳ, ﾋﾌｵﾖﾋﾞﾋｶｿｼｷﾉｳﾖｳNOS
Czech Kožní absces, Absces kůže a podkožního vaziva, Absces kůže a podkožního vaziva NOS
Hungarian Bőr és subcutan szövet tályogja, Bőr abscessusai, Bőr és subcutan szövet abscessus k.m.n., Bőr és subcutan szövet abscessus
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: furuncle (C0242301)

Definition (CHV) hair follicle infection
Definition (CHV) hair follicle infection
Definition (CHV) hair follicle infection
Definition (CHV) hair follicle infection
Definition (CHV) hair follicle infection
Definition (NCI) Bacterial infection of the hair follicle and the surrounding skin. It is caused by Staphylococcus aureus. It presents as a painful, erythematous and swollen skin lesion.
Concepts Disease or Syndrome (T047)
MSH D005667
ICD10 L02.92
SnomedCT 267773002, 156294007, 156303007, 200626008, 267826003, 59843005, 111181004, 416675009
English Furuncles, furuncle (diagnosis), Boil NOS, Furuncle, unspecified, boil, boils, furuncles, furunculus, Boil NOS (disorder), Boils: [Recurrent] or [multiple sites] or [NOS] (disorder), Boils: [Recurrent] or [multiple sites] or [NOS], Furuncle, Boil, Furunculus, Boil of skin AND/OR subcutaneous tissue, Furuncle (morphologic abnormality), Furuncle of skin AND/OR subcutaneous tissue (disorder), Furuncle of skin AND/OR subcutaneous tissue, Boil of skin and subcutaneous tissue, NOS, Boil of skin AND/OR subcutaneous tissue, NOS, Boils, Furuncle NOS, Furuncle (disorder), furuncle
Italian Furunculus, Bolla, Foruncoli
Dutch furunkel, furunkel op aangezicht, Steenpuisten
German Eiterbeule, Eiterbeulen, Furunkel
Japanese せつ, ｾﾂ
Portuguese Furúnculos, Furúnculo
Spanish Forúnculos, Forúnculo, forúnculo de la piel Y/O del tejido celular subcutáneo, furúnculo de la piel Y/O del tejido celular subcutáneo, divieso de la piel Y/O del tejido celular subcutáneo, forúnculo, SAI, forúnculo de piel Y/O tejido celular subcutáneo (trastorno), forúnculo de piel Y/O tejido celular subcutáneo, forúnculo, SAI (trastorno), furúnculo de piel Y/O tejido celular subcutáneo, forúnculo de la piel Y/O del tejido celular subcutáneo (trastorno), Boil NOS, furúnculo (anomalía morfológica), furúnculo, forúnculo, forúnculo (trastorno)
French Furoncles, Furoncle
Czech Furunkl, vředy, furunkly
Hungarian kelés, furunculus
Norwegian Konger, Furunkler
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Abscess soft tissue (C0740694)

Concepts Disease or Syndrome (T047)
Italian Ascesso dei tessuti molli
Japanese 軟部組織膿瘍, ﾅﾝﾌﾞｿｼｷﾉｳﾖｳ
Czech Absces měkkých tkání
Hungarian lágyrész tályog
English Abscess soft tissue
Portuguese Abcesso dos tecidos moles
Spanish Absceso en tejido blando
Dutch abces weke delen
French Abcès de tissu mou
German Abszess an Weichteilen
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Recurrent skin abscesses (C2675144)

Concepts Finding (T033)
English Recurrent skin abscesses, Skin abscesses, recurrent
Derived from the NIH UMLS (Unified Medical Language System)

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