Skin abscess: Difference between revisions
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==Background== | ==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.<ref>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.</ref><ref>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.</ref><ref>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</ref> | *[[MRSA]] is the most common cause of purulent skin and soft-tissue infections.<ref>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.</ref><ref>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.</ref><ref>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</ref> | ||
*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== | ==Clinical Features== | ||
* | [[File:Five day old Abscess.jpg|thumb|Fluctulance on exam]] | ||
*Tender nodular region with surrounding induration | |||
*Fluctuance with or without surrounding erythema | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Duct ectasia | |||
*Cyst | *Cyst | ||
*Vascular malformation | *Vascular malformation | ||
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{{SSTI DDX}} | {{SSTI DDX}} | ||
== | ==Evaluation== | ||
=== | [[File:Isoechoic abscess.png|thumb|Abscess on ultrasound]] | ||
*[[Ultrasound: Soft tissue| | ===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''' | |||
**[[Ultrasound: Soft tissue|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)<ref>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.</ref> | |||
=== | ===Diagnosis=== | ||
* | *Typically a clinical diagnosis, with or without use of bedside [[Ultrasound: Soft tissue|soft tissue ultrasound]] and/or [[I&D]] for confirmation | ||
==Management== | ==Management== | ||
*[[Incision and drainage]] | *[[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<ref>[https://pedemmorsels.com/incision-loop-drainage-abscess/ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels]</ref>, Penrose Drain, or you can cut the proximal cuff of a sterile glove<ref>[https://sinaiem.org/sterile-glove-used-as-a-drain-for-a-skin-abscess/ Sterile Glove Used As a Drain for a Skin Abscess? SinaiEM]</ref> | |||
**Failure rate of 4.1% for loop vessel technique vs 9.8% for conventional packing. <ref>[http://www.ncbi.nlm.nih.gov/pubmed/28917436 Am J Emerg Med, 2018. Comparison of the loop technique with incision and drainage for soft tissue abscesses: A systematic review and meta-analysis.] </ref> | |||
**Other advantage is don’t have to keep coming back to the ER for painful repacking. | |||
**Home Care<ref>[https://pedemmorsels.com/incision-loop-drainage-abscess/ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels]</ref> | |||
***Keep area clean. | |||
***Can cover with gauze to absorb the residual drainage. | |||
***Can shower and/or bathe. | |||
**The loop drain can be removed when:<ref>[https://pedemmorsels.com/incision-loop-drainage-abscess/ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels]</ref> | |||
***Drainage has stopped. | |||
***Cellulitis has improved. | |||
***Usually is within 7-10 days. | |||
*[[Antibiotics]] | *[[Antibiotics]] | ||
**[[TMP/SMX]] x 5 days | **Although withholding antibiotics is part of [[Choosing wisely ACEP]], new evidence suggest antibiotic NNT of 14 to prevent 1 treatment failure<ref>Talan DA, et al. Trimethoprim–Sulfamethoxazole versus placebo for uncomplicated skin abscess. NEJM. 2016; 374(9):823-832.</ref> | ||
**[[TMP/SMX]] DS BID x 5 days<ref>[[EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess]]</ref> | |||
***[[Clindamycin]] is as effective, but with higher adverse events<ref>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</ref> | |||
**Consider more aggressive antibiotic treatment if concomitant [[cellulitis]] | **Consider more aggressive antibiotic treatment if concomitant [[cellulitis]] | ||
==Disposition== | ==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== | ==See Also== | ||
[[Incision and drainage]] | *[[Incision and drainage]] | ||
*[[Cellulitis]] | |||
*[[Ultrasound: Soft tissue]] | |||
==External Links== | ==External Links== | ||
*[https://www.merckmanuals.com/professional/infectious-diseases/biology-of-infectious-disease/abscesses?query=abscess| Merk Manual: Abscess] | |||
*[http://emcrit.org/emnerd/case-pragmatic-wound/ EMNerd: Case of the Pragmatic Wound] | |||
*[http://www.emlitofnote.com/2016/03/are-antibiotics-back-in-favor-for.html Are Antibiotics Back in Favor for Abscesses?] | |||
*[http://www.sonoguide.com/abscess.html Sonoguide: Abscess Assessment] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:ID]] |
Latest revision as of 13:42, 29 May 2022
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