Hair
Skin Abscess
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Skin Abscess
, Furunculosis, Furuncle, Carbuncle, Skin Boil, Recurrent Skin Abscess
See Also
Deep Folliculitis
Incision and Drainage
Perianal Abscess
Paronychia
Hidradenitis Suppurativa
Definitions
Furuncle (Boil, Abscess)
Walled-off
Nodule
of purulent infection forming around a
Hair Follicle
Firm wall with inner fluctuant core
Carbuncle
Coalition of Furuncles
Deeper, more extensive involvement
Require greater degree of debridement
Pathophysiology
Hair Follicle
infection that spreads to deeper tissue (often begins as
Folliculitis
)
Abscess may also form from
Cellulitis
, or
Cellulitis
may form from abscess
Risk Factors
Obesity
Impaired
Neutrophil
function
Corticosteroid
use
Diabetes Mellitus
Intravenous Drug Abuse
Causes
Staphylococcus aureus
(most common)
Streptococcus
species
Mixed
Bacterial Infection
Signs
Tender, erythematous skin mass
Often spontaneously opens and drains to skin surface
Distribution
Occur most commonly in areas of increased friction
Buttock
Extremities
Axilla
Breast
Lactating women: Associated with
Mastitis
Non-Lactating women: Usually subareolar
Biopsy non-subareolar lesions
Precautions
If
IV Drug Abuse
is suspected, consider
Bacterial Endocarditis
(e.g. auscultate for cardiac murmur)
Imaging
Bedside Ultrasound
(
Point of Care Ultrasound
)
Conflicting efficacy in studies
Ultrasound
may alter clinical management by identifying occult abscess (occurred in 50% of cases in one study)
Tayal (2006) Acad Emerg Med 13(4): 384-8 [PubMed]
Ultrasound
is more accurate than clinical exam in one study
Test Sensitivity
up to 97%
Test Sensitivity
and 83-85%
Test Specificity
Gaspari (2012) Crit Ultrasound J 4(1): 5 [PubMed]
Subramaniam (2016) Acad Emerg Med 23(11):1298-306 [PubMed]
Ultrasound
adds little to abscess diagnosis and localization in one study
ED clinicians were as accurate with physical examination as with
Ultrasound
(87%
Test Sensitivity
and 71%
Test Specificity
)
Consider in unclear presentations
But
Ultrasound
only 77%
Test Sensitivity
, 64%
Test Specificity
in theses cases in this study
Marin (2013) Acad Emerg Med 20(6): 545-53 [PubMed]
Management
Acute Episode
Trial of warm compresses for small abscesses
Incision and Drainage
Primary, definitive, most critical step in Skin Abscess management
Antibiotic indications (in addition to
Incision and Drainage
)
Antibiotics are usually not required for an isolated abscess without
Cellulitis
once the lesion is incised and drained
Antibiotics do not shorten course of abscess
However recurrence rate may be less with antibiotic use
Talan (2016) N Engl J Med 374(9): 823-32 +PMID:26962903 [PubMed]
Antibiotic indications (post-drainage)
Cellulitis
(see
Cellulitis
for antibiotic choices)
Serious comorbidity such as
Diabetes Mellitus
, immunosuppression or extremes of age
Multiple sites of infection
Systemic symptoms
Rapid progression with concurrent
Cellulitis
Infection involving face, hand or genitalia
Associated septic phlebitis
Unreliable follow-up
Large abscess (e.g. 5 cm and greater, Carbuncle)
Failure to improve after
Incision and Drainage
Antibiotics for Skin Abscess with
Cellulitis
(in addition to
Incision and Drainage
)
See
Cellulitis
Management
As noted above, antibiotics are not needed for simple abscess without
Cellulitis
Agents for
MRSA
Trimethoprim Sulfamethoxazole
(
Septra
,
Bactrim
) DS orally twice daily for 5-10 days
Doxycyline 100 mg orally twice daily for 5-10 days
Clindamycin
300 mg (or 450 mg if BMI>40) rally three times daily for 5-10 days
Linezolid
600 mg orally twice daily for 5-10 days
Vancomycin
15 mg/kg every 12 hours
Agents for known
MSSA
Dicloxacillin
500 mg orally three to four times daily for 5-10 days
Cephalexin
(
Keflex
) 500 mg orally three to four times daily for 5-10 days
Nafcillin
(or
Oxacillin
) 1 g IV every 4 hours
Cefazolin
(
Ancef
) 1 g IV every 8 hours
References
(2017) Sanford Guide, Skin Abscess (accessed 1/1/2018 on IOS app)
Management
Recurrent Abscess
Optimize personal hygiene
Regular bathing and
Hand Washing
with soap and water or
Alcohol
-based hand cleansers
Reduce transmission risk
Active
Skin Infection
s should be cleaned and covered with a dry dressing at least daily (or more as needed)
Avoid sharing personal items (razors, towels, wash cloths and other linens)
Wash high contact surfaces (e.g. doorknobs, counters, toilet seats) with commercial cleansers
Mupirocin
(
Bactroban
)
Apply intranasally bid for 5 days
Reduces nasal
Staphylococcus aureus
carriage
Antiseptic body cleansers (e.g. Hibiclens or dilute bleach bath)
Hibiclens
Wash completely with hibiclens daily for 5-14 days
Dilute bleach bath
Dilute bleach: 1 teaspoon bleach per gallon water OR
One quarter cup bleach per 20 gallons water (or 1/4 tub of water)
Soak in the dilute bleach for 15 minutes twice weekly for 3 months
Shower to rinse off bleach completely
Make certain to rinse and dry feet before walking across carpet (and bleaching the carpet)
Other measures with minimal evidence (not recommended)
Systemic antibiotic protocols (10 day course)
Not generally recommended (poor efficacy, increased resistance rates)
Rifampin
600 mg PO qd and
Trimethoprim-Sulfamethoxazole (
Bactrim
,
Septra
) DS twice daily
Clindamycin
four times daily
Vitamin C
1 gram per day
Effective in those with impaired
Neutrophil
function
Complications
Cellulitis
Gangrene
Necrotizing Fasciitis
Hidradenitis Suppurativa
Recurrent Furunculosis
References
Chan (2014) Crit Dec Emerg Med 28(9): 2-7
Derksen in Pfenninger (1994) Procedures, p. 50-3
Gilbert (2002) Sanford Guide, p. 36-37
Carroll (1996) Postgrad Med 100(3):311-22 [PubMed]
Stulberg (2002) Am Fam Physician 66(1):119-24 [PubMed]
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