Incision and Drainage of Cutaneous Abscess

A cutaneous abscess is identified by a fluctuance or compressible softness in skin surrounded by induration, inflammation, warmth, and tenderness. Furuncles are superficial and result from abscess formation in a sweat gland or hair follicle. Carbuncles are deeper and extend into the subcutaneous tissue. Offending bacteria include Staphylococcus aureus, streptococci, and occasionally gram-negative rods. These infections can be severe in patients with diabetes or vascular disease. Primary treatment of an abscess is surgical drainage. An area of induration alone with no fluctuance indicates isolated cel-lulitis and is treated with antibiotics and warm compresses.

When performing an incision and drainage of an abscess, the skin is prepared with a sterilizing and cleansing agent. Local anesthetics do not work well in the acidic environment of an abscess, so a ring or field block can be infiltrated around the periphery of the lesion. Superficial cooling of the surface of the skin with ethyl chloride or liquid nitrogen can also provide brief anesthesia for a stab incision.

A linear incision is made over the area of maximal fluc-tuance and has been shown to heal in a shorter time than deroofing procedures used in the past (S0rensen et al., 1987). Once the incision is made into the center of the abscess with a #11 blade, the abscess cavity is probed with a curved hemostat to disrupt any loculations. The abscess cavity is packed with /- to 1-inch gauze to prevent early superficial wound closure and allow secondary healing. Primary closure is not recommended (Korownyk, 2007). A bulky sterile dressing can be applied to absorb any drainage and the packing and dressing changed every 1 to 2 days or when soiled. Evidence does not support using oral antibiotics after surgical drainage. Routine swabbing for culture in immunocompetent individuals is not recommended (Korownyk, 2007). Patients are educated on wound care and return in 2 to 7 days for follow-up. (See Tuggy Video: Abscess Incision and Drainage.)

Recurrent skin abscesses should be investigated based on location. Crohn's disease, subcutaneous fistulas, and piloni-dal cysts can present as recurrent cutaneous abscesses. MRSA should be suspected in recurrences as well.

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