subcutaneous abscess; boil
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Etiology
- cellulitis
- lymphadenitis
- colonization with Staphylococcus aureus (MRSA common)
Pathology
- mixture of anaerobes & aerobes
- Staphylococcus aureus is the predominant organism
Clinical manifestations
- painful induration
- localized erythema
- most common sites: neck, axilla, groin
- may occur at any site on the skin
*images[6]
Management
- incision & drainage (I&D)
- fine needle aspiration with 22 guage needle if fluctuance is questionable
- scalpel incision
- larger abscesses
- probe with a sterile swab & break up loculations
- lavage with saline or hydrogen peroxide
- pack with 1/4-1/2 inch strip gauze
- cover with 4 x 4 inch gauze pad
- re-evalute in 24 hours (face) or 24-48 hours
- repack wound until erythema, drainage & induration resolve
- topical dressing until wound has healed
- indications for antibiotic coverage
- immunosuppressed patients
- patients with facial lesions
- systemic manifestations (fever, tachycardia)
- diabetes mellitus
- peripheral vascular disease
- abscesses > 2 cm in diameter
- extensive surrounding erythema suggesting cellulitis[10]
- not necessary for I&D in children[2]
- antibiotic agents
- avoid beta-lactam due to high incidence of MRSA
- especially recently hospitalized patients or nursing home residents[10]
- TMP/SMX (320 mg/1600 mg twice a day) for 7 days results in marginally higher cure rate (93% vs 86%)[7]
- TMP/SMX if streptococci not a concern[3]
- TMP/SMX or clindamycin for 10 days improves short-term outcomes in patients after I&D of small skin abscesses[9]
- doxycycline if TMP-SMX contraindicated
- clindamycin, penicillin, cephalexin if non-purulent (Streptococcus)
- linezolid
- intravenous vancomycin in hospitalized patients[1]
- avoid beta-lactam due to high incidence of MRSA
- prevention
- hygiene
- intranasal mupirocin to reduce nasal colonization with Staphyloccus
More general terms
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Additional terms
References
- ↑ Jump up to: 1.0 1.1 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 17 American College of Physicians, Philadelphia 1998, 2009, 2015
- ↑ Jump up to: 2.0 2.1 Duong M et al Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med 2009 May 1 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19409657 <Internet> http://dx.doi.org/10.1016/j.annemergmed.2009.03.014
- ↑ Jump up to: 3.0 3.1 Schmitz GR et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010 Sep; 56:283. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20346539
- ↑ Kemper AR et al. Management of skin abscesses by primary care pediatricians. Clin Pediatr (Phila) 2011 Jun; 50:525. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21262755
- ↑ Singer AJ and Talan DA Management of Skin Abscesses in the Era of Methicillin- Resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039-1047. March 13, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24620867 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMra1212788
- ↑ Jump up to: 6.0 6.1 DermNet NZ. Cutaneous abscess (images) http://www.dermnetnz.org/bacterial/abscess.html
- ↑ Jump up to: 7.0 7.1 Talan DA, Mower WR, Krishnadasan A et al Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med 2016; 374:823-832. March 3, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26962903 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1507476
- ↑ Wilbur MB, Daum DS, Gold HS Skin Abscess N Engl J Med 2016; 374:882-884. March 3, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26962909 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMclde1600286
- ↑ Jump up to: 9.0 9.1 Daum RS, Miller LG, Immergluck L et al A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med 2017; 376:2545-2555. June 29, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28657870 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1607033
- ↑ Jump up to: 10.0 10.1 10.2 NEJM Knowledge+ Dermatology