Skin abscess
Background
- Localized collection of pus surrounded by inflamed tissue, usually caused by bacterial infection
- MRSA is the most common cause of purulent skin and soft-tissue infections.[1][2][3]
- Standard skin abscess are not typically due to spider bites and should not be diagnosed as such
Terminology
- Furuncles (i.e. boils) are skin abscesses caused by staphylococcal infection, which involve a hair follicle and surrounding tissue
- Carbuncles are clusters of furuncles connected subcutaneously, causing deeper suppuration and scarring.
Clinical Features
- Tender nodular region with surrounding induration
- Fluctuance with or without surrounding erythema
Differential Diagnosis
- Duct ectasia
- Cyst
- Vascular malformation
Skin and Soft Tissue Infection
- Cellulitis
- Erysipelas
- Lymphangitis
- Folliculitis
- Hidradenitis suppurativa
- Skin abscess
- Necrotizing soft tissue infections
- Mycobacterium marinum
Look-A-Likes
- Sporotrichosis
- Osteomyelitis
- Deep venous thrombosis
- Pyomyositis
- Purple glove syndrome
- Tuberculosis (tuberculous inflammation of the skin)
Evaluation
Workup
- Labs
- Not usually indicated
- Glucose may help identify undiagnosed diabetes, if suspected
- For febrile or systemically ill patients, obtain blood cultures, lactate, renal function, and CK
- Imaging
- Soft tissue ultrasound can differentiate between abscess and cellulitis
- Assess for fluid collection and swirl within the collection
- Recent small studies have shown limited utility to bedside ultrasound in this capacity as it rarely leads to change in management (i.e. when a provider feels there is an abscess present, ultrasound shows an abscess and when there is diagnostic uncertainty the ultrasound usually is unequivocal as well)[4]
- Soft tissue ultrasound can differentiate between abscess and cellulitis
Diagnosis
- Typically a clinical diagnosis, with or without use of bedside soft tissue ultrasound and/or I&D for confirmation
Management
- Incision and drainage
- Packing
- Abscess >5 cm in diameter
- Pilonidal abscess
- Abscess in an immunocompromised or diabetic patient
- Alternative to packing is loop drainage technique with vessel ties[5], Penrose Drain, or you can cut the proximal cuff of a sterile glove[6]
- Failure rate of 4.1% for loop vessel technique vs 9.8% for conventional packing. [7]
- Other advantage is don’t have to keep coming back to the ER for painful repacking.
- Home Care[8]
- Keep area clean.
- Can cover with gauze to absorb the residual drainage.
- Can shower and/or bathe.
- The loop drain can be removed when:[9]
- Drainage has stopped.
- Cellulitis has improved.
- Usually is within 7-10 days.
- Antibiotics
- Although withholding antibiotics is part of Choosing wisely ACEP, new evidence suggest antibiotic NNT of 14 to prevent 1 treatment failure[10]
- TMP/SMX DS BID x 5 days[11]
- Clindamycin is as effective, but with higher adverse events[12]
- Consider more aggressive antibiotic treatment if concomitant cellulitis
Disposition
Admission
- Reserved for significantly ill patients or those requiring surgical intervention
Discharge
- Appropriate for majority of patients
- Follow up in 2 days for wound check
See Also
External Links
- Merk Manual: Abscess
- EMNerd: Case of the Pragmatic Wound
- Are Antibiotics Back in Favor for Abscesses?
- Sonoguide: Abscess Assessment
References
- ↑ Maligner D et al. The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in skin abscesses presenting to the pediatric emergency department. N C Med J. 2008 Sep-Oct;69(5):351-4.
- ↑ Pickett A et al. Changing incidence of methicillin-resistant staphylococcus aureus skin abscesses in a pediatric emergency department. Pediatr Emerg Care. 2009 Dec;25(12):831-4.
- ↑ Bradley W. Frazee et al. High Prevalence of Methicillin-Resistant Staphylococcus aureus in Emergency Department Skin and Soft Tissue Infections http://dx.doi.org/10.1016/j.annemergmed.2004.10.011
- ↑ Effect of initial bedside ultrasonography on emergency department skin and soft tissue infection management Mower WR, Crisp JG, Krishnadasan A, et al. Ann Emerg Med. 2019;74(3):372-380.
- ↑ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels
- ↑ Sterile Glove Used As a Drain for a Skin Abscess? SinaiEM
- ↑ Am J Emerg Med, 2018. Comparison of the loop technique with incision and drainage for soft tissue abscesses: A systematic review and meta-analysis.
- ↑ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels
- ↑ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels
- ↑ Talan DA, et al. Trimethoprim–Sulfamethoxazole versus placebo for uncomplicated skin abscess. NEJM. 2016; 374(9):823-832.
- ↑ EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess
- ↑ Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med. 2017;376(26):2545-2555. doi:10.1056/NEJMoa1607033