CUTANEOUS ABSCESS

FURUNCLES AND
CARBUCLES

 DR AZMMAT GOWHER KHAN

A cutaneous abscess is a
localized collection of pus
in the skin and may occur
on any skin surface.
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 sometimes erythematous.
 They vary in size, typically 1 to 3 cm in length, but
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.
ETIOLOGY
 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
Diagnosis
Examination
Gram stain and culture
to identify MRSA
Diagnosis is usually obvious by
examination. Gram stain and
culture are recommended,
primarily to identify MRSA
Treatment
Incision and drainage
 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.
Furuncles and Carbuncles
 Furuncles also known as 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.
 They are smaller and more superficial than
subcutaneous abscesses
 Both furuncles and carbuncles may affect healthy
young people but are more common in the obese,
the immunocompromised (including those
with neutrophil defects), the elderly, and possibly
those with diabetes.
 Clustered cases may occur among those living in
crowded quarters with relatively poor hygiene or
among contacts of patients infected with virulent
strains.

 Predisposing factors include bacterial
colonization of skin or nares,
hot and humid climates, and occlusion
or abnormal follicular anatomy (eg,
comedones in acne).
 Methicillin-resistant Staphylococcus
aureus(MRSA) is a common cause.
 Furuncles are common on the neck, breasts, face, and
buttocks.
 They are uncomfortable and may be painful when
closely attached to underlying structures (eg, on the
nose, ear, or fingers).
 Appearance is a nodule or pustule that discharges
necrotic tissue and sanguineous pus.
 Carbuncles may be accompanied by fever and
prostration
Treatment
Drainage
Often antibiotics
effective against MRSA
 Abscesses are incised and drained
 . Intermittent hot compresses are used to
facilitate drainage.
 Antibiotics, when used, should be effective
against MRSA, pending culture and
sensitivity test results.
 In afebrile patients, treatment of a single
lesion < 5 mm requires no antibiotics.
 If a single lesion is ≥ 5 mm, an oral
antibiotic is given for 5 to 10 days
Systemic antibiotics are also
need for
Lesions < 5 mm that do not
resolve with drainage
Evidence of expanding cellulitis
Immunocompromised patients
Patients at risk of endocarditis
 Furuncles frequently recur and can be
prevented by applying liquid soap
containing either chlorhexidine gluconate
with isopropyl alcohol or 2 to 3%
chloroxylenol and by giving maintenance
antibiotics over 1 to 2 mo.

 Patients with recurrent furunculosis should

be treated for predisposing factors such as
obesity, diabetes, occupational or industrial
exposure to inciting factors, and nasal
carriage of S. aureus or MRSA colonization.
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