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Incision and Drainage of Cutaneous Abscesses

  • Editor(s): Todd W Thomsen, MD, Gary S Setnik, MD, FACEP
  • Section Editor(s): Phillip M Harter, MD
  • Contributor(s): Carmie Chan, MD
PRE-PROCEDURE
INDICATIONS

Surgical incision and drainage is the definitive treatment of a soft-tissue abscess; antibiotics alone are ineffective. The drainage of a suppurative focus results in a marked resolution of symptoms in uncomplicated cases.
CONTRAINDICATIONS
  • Infection without abscess formation
    • Premature incision before localization of pus will not be curative and theoretically may be deleterious, because extension of the infectious process and, rarely, bacteremia from manipulation can result.
EQUIPMENT
  • A standard suture tray with a scalpel and packing material added
  • Sterile gauze
  • Skin antiseptic agent
  • Local anesthetic (1% lidocaine)
  • Syringe with 25-gauge needle for anesthetic administration
  • No. 11 blade scalpel
  • Hemostat
  • Syringe and saline for irrigation
  • Packing gauze
  • Dressing supplies
ANATOMY
  • Epithelium: outer layer of stratified squamous epithelium derived from cornified skin cells
  • The dermis is less dense and contains terminal capillaries and nerve endings.
    • The reticular layer is the deepest layer of the dermis and contains the origins of hair follicles, sweat glands, and sebaceous glands.
Cutaneous abscess.
Figure 2 :  Cutaneous abscess.

Equipment
Figure 4 :  Equipment

Anatomy of the skin. Adapted from Robinso JK, Anderson ER: Skin structure and surgical anatomy. In Robinson JK, Hanke WC, Sengelmann R, Siegel D: Surgery of the Skin. Philadelphia, Mosby, an imprint of Elsevier, 2005, p. 4.
Figure 5 :  Anatomy of the skin. Adapted from Robinso JK, Anderson ER: Skin structure and surgical anatomy. In Robinson JK, Hanke WC, Sengelmann R, Siegel D: Surgery of the Skin. Philadelphia, Mosby, an imprint of Elsevier, 2005, p. 4.


PROCEDURE
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Create a field block around the abscess.
Figure 8 :  Create a field block around the abscess.

Incise the abscess cavity.
Figure 9 :  Incise the abscess cavity.

Use a hemostat to break up loculations.
Figure 10 :  Use a hemostat to break up loculations.

Irrigate the abscess cavity.
Figure 12 :  Irrigate the abscess cavity.

Pack the abscess with gauze.
Figure 13 :  Pack the abscess with gauze.


POST-PROCEDURE
CARE
  • Advise the patient to keep the area elevated.
  • Instruct the patient to not disturb the dressing/splint until the first follow-up visit.
  • Provide appropriate analgesia. Drainage relieves most of the pain of an abscess, but postoperative analgesics may be required.
  • Arrange for the follow-up examination.
  • Therapeutic antibiotics
    • The usefulness of administration of antibiotics remains unproven for prophylaxis against and treatment of routine cutaneous abscesses.
    • Consider antibiotics for immunocompromised patients and for the immunocompetent patient with “significant” cellulitis, lymphangitis, or systemic symptoms, such as chills or fever.
  • Management of cutaneous community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA)
    • When cutaneous CA-MRSA infection presents as an abscess, incision and drainage remains the mainstay of therapy. Antibiotic therapy, in addition to appropriate surgical intervention, may be helpful to limit the spread of infection.
  • Management of facial abscesses
    • Handle facial abscesses carefully and recheck the patient frequently.
    • Treatment with antistaphylococcal antibiotics and warm soaks following incision and drainage has been recommended pending resolution of the process.
    • Wounds in cosmetically important areas may require revision once healing is complete. Inform patients of this possibility early on in their care.
COMPLICATIONS
  • Transient bacteremia
  • Thrombophlebitis of the cavernous sinus (after incision of central facial abscesses)
  • Neurovascular injury
  • Spread of infection
  • Scar formation
  • Recurrence of infection
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