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Cutaneous Abscess

by A. Damian Dhar, MD, JD

A cutaneous abscess is a localized collection of pus in the skin and may occur on any skin surface. Symptoms and signs are pain and a tender and firm or fluctuant swelling. Diagnosis is usually obvious by examination. Treatment is incision and drainage.

Bacteria causing cutaneous abscesses are typically indigenous to the skin of the involved area. For abscesses on the trunk, extremities, axillae, or head and neck, the most common organisms are Staphylococcus aureus and streptococci. In recent years, methicillin-resistant  S. aureus (MRSA) has become a more common cause.

Abscesses in the perineal (ie, inguinal, vaginal, buttock, perirectal) region contain organisms found in the stool, commonly anaerobes or a combination of aerobes and anaerobes. Carbuncles and furuncles are follicle-based cutaneous abscesses with characteristic features (see Furuncles and Carbuncles).

Cutaneous abscesses tend to form in patients with bacterial overgrowth, antecedent trauma (particularly when a foreign body is present), or immunologic or circulatory compromise.

Symptoms and Signs

Cutaneous abscesses are painful, tender, indurated, and usually erythematous. They vary in size, typically 1 to 3 cm in length, but are sometimes much larger. Initially the swelling is firm; later, as the abscess points, the overlying skin becomes thin and feels fluctuant. The abscess may then spontaneously drain. Local cellulitis, lymphangitis, regional lymphadenopathy, fever, and leukocytosis are variable accompanying features.

Diagnosis

  • Examination

  • Culture to identify MRSA

Diagnosis is usually obvious by examination. Culture is recommended, primarily to identify MRSA.

Conditions resembling simple cutaneous abscesses include hidradenitis suppurativa (see Hidradenitis Suppurativa) and ruptured epidermal cysts. Epidermal cysts (often incorrectly referred to as sebaceous cysts) rarely become infected; however, rupture releases keratin into the dermis, causing an exuberant inflammatory reaction sometimes clinically resembling infection. Culture of these ruptured cysts seldom reveals any bacteria. Perineal abscesses may represent cutaneous emergence of a deeper perirectal abscess or drainage resulting from Crohn disease via a fistulous tract. These other conditions are usually recognizable by history and rectal examination.

Treatment

  • Incision and drainage

  • Sometimes antibiotics

Some small abscesses resolve without treatment, coming to a point and draining. Warm compresses help accelerate the process. Incision and drainage are indicated when significant pain, tenderness, and swelling are present; it is unnecessary to await fluctuance. Under sterile conditions, local anethesia is given as either a lidocaine injection or a freezing spray.

Patients with large, extremely painful abscesses may benefit from IV sedation and analgesia during drainage. A single puncture with the tip of a scalpel is often sufficient to open the abscess. After the pus drains, the cavity should be bluntly probed with a gloved finger or curette to clear loculations and then irrigated with 0.9% saline solution. Some clinicians pack the cavity loosely with a gauze wick that is removed 24 to 48 h later. Local heat and elevation may hasten resolution of inflammation.

Antibiotics are unnecessary unless the patient has signs of systemic infection, cellulitis, multiple abscesses, immunocompromise, or a facial abscess in the area drained by the cavernous sinus. In these cases, empiric therapy should be started with a drug active against MRSA (eg, trimethoprim/sulfamethoxazole, clindamycin; for severe infection, vancomycin) pending results of bacterial culture.

Key Points

  • Pathogens reflect flora of the involved area (eg, S. aureus and streptococci in the trunk, axilla, head, and neck), but MRSA has become more common.

  • Culture abscesses to identify MRSA.

  • Drain abscesses accompanied by significant pain, tenderness, and swelling and provide adequate analgesia and, when indicated, sedation.

  • Avoid antibiotics in simple abscesses.

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • VANCOCIN
  • XYLOCAINE
  • CLEOCIN
  • No US brand name

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