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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