If an abscess is ready to be drained it will be fluctuant (a soft or "squishy"
feeling under the skin), but the feeling alone can be deceiving. Unless the
site has opened spontaneously and is draining, do a needle aspiration. Anesthetize
a small central area in the surface of a suspected abscess and insert an 18-
or 20-gauge needle attached to a syringe.
If there is no purulent aspirant, send the patient out using warm compresses
4 times a day for 15 minutes, with instructions to return for any systemic
symptoms of infection or local increased size, pain or drainage. Prescribe
antibiotics (e.g. Augumentin, Dicloxacillan, Keflex, 500 mg qid for 7 days)
if surrounding cellulitis is present and appropriate pain meds.(eg. Ibuprofen
800 mg, Lortab 5/50 tid especially in axillary abscesses) Consider checking
the blood glucose, as undiagnosed or poorly controlled diabetics frequently
get skin abscesses.
If you are able to withdraw a purulent substance it is time for an incision
and drainage (I&D). To do this, clean the skin with betadine. Use a ring block
with 1% or 2% lidocaine with epi. To minimize the burning administer with
a 27-gauge needle. Also, adding sodium bicarb to lidocaine in a 1:10 ratio
will neutralize the acidity, and burn less when injected. Make an approximately
1 centimeter long incision at the center of the abscess. Insert a sterile
cotton swab and break up loculations (smaller adjoining cavities separated
by tissue within an abscess). Apply gentle pressure and express as much of
the pus as possible. Clean the surrounding area. Pack loosely with sterile
iodoform gauze. Cover with gauze dressing. Prescribe pain meds and antibiotics
if surrounding tissue demonstrates cellulitis. Irrigation with normal saline
with moderate pressure is not a bad idea, though not essential to good healing,
since the wound packing will be changed several times.
Wound care instructions should include detailed signs and symptoms of increasing infection. Stress the importance of keeping area dry. Have the patient leave packing in place but change outside dressing as often as needed. The patient should return in 1 to 2 days for recheck or sooner if needed due to fever, if the area of redness increases in size or if
flu-like symptoms develop in case it is a new onset of sepsis. I usually ask if they can bring someone with them at that time and teach both folks how to change the packing. The more purulent exudate that was intially drained during the I&D the more frequently the packing should be changed. An actively draining site can be changed 2 times daily. A modest amount of exudate and the packing can be changed one time daily. If there is little drainage
once every other day will work fine. The packing is used to keep the site from closing up while pus is still being produced. No new pus-no need to pack. Changing the packing can be done any where from 2 times a day to every 2 days.
