How To Incise and Drain an Abscess

Soft-tissue abscess

None

Certain abscesses may require drainage in an operating room.

Uncertainty whether lesion represents focal cellulitis with induration and swelling or an actual abscess (ultrasonography may be helpful)

Abscesses close to major neurovascular structures (eg, the axilla, antecubital fossa, posterior knee, groin area, neck)

Infections of the hand other than those limited to the distal finger (because of complicated anatomy and small areas)

Facial infections (because adequate anesthesia is difficult and the cavernous venous sinus is nearby for facial abscesses above the upper lip and below the brow)

Large or deep abscesses (alternatively, experienced practitioners with available technology may consider doing ultrasound or CT-guided percutaneous needle aspiration)

Bacteremia Bacteremia Bacteremia is the presence of bacteria in the bloodstream. It can occur spontaneously, during certain tissue infections, with use of indwelling genitourinary or IV catheters, or after dental... read more and sepsis Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more

Chronic draining sinuses and fistulas, secondary to inadequate drainage of deep or complicated abscesses

Cleansing solution, such as povidone-iodine or chlorhexidine

21- and 25-gauge needles

10-mL syringe

Local anesthetic, such as 1% lidocaine

Irrigation syringe

Hemostat or small forceps

#11 scalpel

Culture swab

Packing material, such as ½- to 1-cm sterile gauze strip

Absorptive bulk dressing (such as 4 × 4 gauze squares and tape; circular dry gauze wrap on extremities)

Nonsterile gloves

Varies by location

Patient comfort with excellent exposure of abscess

Consider parenteral analgesia (eg, fentanyl 1 to 2 mcg/kg IV) for patients with significant pain, anxiety, or large abscesses.

If available, point-of-care ultrasound may be used to identify extent of abscess and possible loculations.

Cleanse the site with povidone-iodine or chlorhexidine solution.

Inject local anesthetic using a 25-gauge needle either along the line of incision over the dome of the abscess, or, more effectively, as a field block around the entire abscess; in some locations, a nerve block also can be used.

If injecting along the incision, be careful not to inject into the abscess cavity, which is painful and fails to numb the skin.

To create a field block, inject local anesthetic in a diamond-shaped pattern around the entire abscess. Start at one of the apices of the diamond and inject for the length of the needle, then reinsert it through anesthetized skin as you continue around the abscess.

Make a linear incision over the full length of the abscess using a #11 scalpel, following skin creases if possible.

Gently squeeze the wound to express the pus.

Culture of the abscess is not routinely necessary but may be done in patients who have systemic symptoms and signs, severe local infection (cellulitis), recurrent abscesses, or failure of initial antibiotic treatment and in patients at the extremes of age or who are immunocompromised.

Sweep a hemostat or forceps around the abscess cavity to break up loculations. Consider using a blunt-ended, rigid suction device to extract pus from large or deep abscesses, which also assists in breaking up loculations.

Correct predisposing conditions, such as obstruction of natural drainage (eg, due to redundant skin folds) or the presence of a foreign body.

If it is difficult to completely evacuate the abscess contents, irrigate the cavity with normal saline solution.

Although packing was commonly done in the past, it is not considered necessary except for pilonidal abscesses > 5 cm and, possibly, abscesses in immunocompromised patients and those with diabetes.

Place an absorbent gauze pad over the wound. If on an extremity, secure the pad with circular dry gauze wrap. Splint the affected part if possible, particularly if a joint is affected.

Reevaluate and redress the wound in 24 to 48 hours. Exceptions are some small abscesses, such as paronychias or small furuncles, which do not need to be monitored as closely.

Drainage relieves most of the pain of an abscess, but postoperative analgesics may be required.

Instruct the patient to elevate the wound and not disturb the dressing and splint before the first follow-up visit.

Any packing may be removed once there is healthy granulation tissue throughout the cavity and there is no longer any drainage. Have the patient begin warm soaks and gentle hydrostatic debridement at home (ask the patient to hold the skin incision open and direct the shower or faucet spray into the abscess cavity). Continue dressing changes every 1 to 2 days and follow-up visits as needed until fully healed.

Patients should be reevaluated if they have worsening pain, increased drainage, or spreading erythema.

Do not underestimate the need for analgesia. Inadequate analgesia deters thorough wound care.

The skin of a pointing abscess is very thin, making it difficult to inject local anesthetic into the skin rather than the abscess cavity; use a field block instead.

Incising skin before pus localizes into an abscess is not curative and may even extend the infectious process. If it is unclear whether pus is present, do ultrasonography or have the patient apply heat and take antibiotics and analgesics (eg, NSAIDs, acetaminophen) and reevaluate in 24 to 48 hours.

Without proper incision and drainage, spontaneous rupture and drainage may occur, sometimes leading to the formation of chronic draining sinuses. Incomplete resorption may leave a cystic loculation within a fibrous wall that may become calcified.

Perirectal abscesses Treatment An anorectal abscess is a localized collection of pus in the perirectal spaces. Abscesses usually originate in an anal crypt. Symptoms are pain and swelling. Diagnosis is primarily by examination... read more have a high morbidity and mortality if incision and drainage are incomplete and should be evaluated by a surgeon. Patients with large and deep abscesses should be admitted to the hospital for evaluation and treatment under general or spinal anesthesia.

A facial abscess above the upper lip and below the brow may drain into the cavernous sinus, so manipulation of an abscess in this area may predispose to septic thrombophlebitis. After incision and drainage, treat with antistaphylococcal antibiotics and warm soaks and have frequent follow-up visits.

When doing a field block, after the first injection always reinsert the needle through anesthetized skin to minimize the number of painful pricks.

For breast abscesses, ultrasound-guided needle aspiration, as opposed to formal incision and drainage, is becoming the standard of care.

Sebaceous cyst abscesses have a pearly white capsule. The capsule must be removed for complete healing either at the time of abscess drainage or at a follow-up visit once inflammation has resolved.

For paronychia, consider simply lifting the eponychial fold away from the nail matrix to allow the pus to drain; after this, adequate drainage is likely.