Differential Diagnosis

Management

• Incision and drainage is the primary treatment for single, simple boils. Warm compresses or soaks can help to encourage spontaneous drainage.

• Bacterial culture should be sent, especially if the patient will be treated with antibiotic therapy.

• Systemic antibiotics are recommended for extensive disease or for multiple sites of infection, associated systemic symptoms, evolving cellulitis, immunosuppression, very young children or elderly, boils that are located in an area difficult to drain such as the face, hand, or genitalia, and when there is a lack of response to incision and drainage alone.

• In children, first-line antibiotics include dicloxacillin (12.5 to 25 mg/kg/day divided q6 hours), or cephalexin (25 to 50 mg/kg/day divided q6-12 hours).

• Personal hygiene measures to prevent autoinoculation or transmission include the following:

  • Keep draining wounds covered with clean, dry bandages

  • Regular bathing and cleaning of hands with soap and water or an alcohol-based hand gel, particularly after touching infected skin or an item that has directly contacted a draining wound

  • Similarly, keep high-touch surfaces clean

• Furunculosis may become recurrent in cases where patients are carriers of S. aureus or where there is ongoing transmission among close contacts.

• For recurrent furunculosis, treatment includes emphasis on the hygiene measures above and one of the following decolonization strategies:

  • Mupirocin ointment intranasally twice daily for 5 to 10 days

  • Skin antiseptic solution (e.g., chlorhexidine) for 5 to 14 days or dilute bleach baths (see Bleach Baths in The Companion eBook Edition)

  • An oral antibiotic in combination with rifampin (if the strain is susceptible) may be considered for decolonization if infections recur despite above measures

• Close contacts should be evaluated for evidence of infection.

• The clinical spectrum of MRSA infection ranges from asymptomatic colonization, to skin and soft tissue infection, to life-threatening invasive infection.

• Skin infections due to MRSA are becoming increasingly prevalent worldwide.

• In children, MRSA commonly presents as recurrent furunculosis or bacterial superinfection of atopic dermatitis.

• Risk factors include skin trauma, frequent skin-to-skin contact, sharing potentially contaminated personal items or equipment, and frequent exposure to antimicrobial agents.

• Consider MRSA in cases of treatment failure.

• Even if caused by MRSA, incision and drainage of a simple abscess is often sufficient as monotherapy.

• Empiric systemic treatment for skin infections secondary to MRSA should be guided by the type and site of infection and the local antibiotic susceptibility patterns.

• Typically, clindamycin, trimethoprim-sulfamethoxazole, a tetracycline, and linezolid are active against MRSA.

Helpful Hint

• Drainage is an essential part of the treatment of a furuncle.

Points to Remember

• Tetracyclines should not be used in children <8 years of age.

• In general, oral antibiotics are used for treatment of bacterial skin infections and not for decolonization.