11.10 Cutaneous Abscess or Pustule
With or without a history of minor trauma (such as an
embedded foreign body) the patient has localized pain,
swelling and redness of the skin. The area is warm, firm,
and, usually fluctuant to palpation. There is sometimes
surrounding cellulitis or lymphangitis and, in the more
serious case, fever. There may be an spot where the abscess
is close to the skin, the skin is thinned, and pus may break
through to drain spontaneously ("pointing").
A pustule will appear only as a cloudy tender vesicle
surrounded by some redness and induration, and occasionally
will be the source of an ascending lymphangitis.
What to do:
- A pustule may not require any anesthesia for drainage.
Simply snip open the cutaneous roof with fine scissors or
an inverted #11 blade, grasp an edge with pickups and
excise the entire overlying surface. Cleanse the open
surface with normal saline and cover it with povidone-
iodine ointment and a dressing.
- When the location of an abscess cavity is uncertain,
attempt to aspirate it with a # 18 gauge needle after
prepping the area with povidone-iodine. If an abscess
cavity cannot be located, send the patient out on
antibiotics and intermittent warm moist compresses and
have him seen again in 24 hours.
- When the abscess is pointing or has been located by needle
aspiration, prepare the overlying skin for incision and
drainage with povidone-iodine solution. Anesthetize the area
with regional field block, accomplished by injecting a ring
of subcutaneous 1% lidocaine solution approximately l cm
away from the erythematous border of the abscess. In
addition, inject lidocaine into the roof of the abscess
along the line of the projected incision.
- The incision should be made with a #11 or #15 blade at
the most dependent area of fluctuance. It should be large
and directed along the relaxed skin tension lines to
reduce future scarring
- In larger abscesses insert a hemostat into the cavity to
break up any loculated collections of pus. The cavity may
then be irrigated with normal saline and loosely packed
with Iodoform or plain gauze. Leave a small wick of this
gauze protruding through the incision to allow for
continued drainage and easy removal after 48 hours.
- The patient should be instructed to use intermittent warm
water soaks or compresses for a few days when there is no
packing used or after packing is removed.
- A dressing should be provided to collect continued
What not to do:
- Do not incise an abscess that lies in close proximity to a
major vessel, such as in the axilla, groin or antecubital
space, without first confirming its location and nature by
- Do not treat deep infections of the hands as simple
cutaneous abscesses. When significant pain and swelling
exists, or there is pain or range of motion of a finger,
seek surgical consultation
Either trauma or obstruction of glands in the skin can lead
to cutaneous abscesses. Incision and drainage is the
definitive therapy for these lesions and, therefore, routine
cultures and antibiotics are generally not indicated.
Exceptions exist in the immunologically suppressed patient,
the toxic, febrile patient, or where there is a large area
of cellulitis or lymphangitis, in which cases an antibiotic
can be selected on the basis of a Gram stain or
presumptively based on body location.
It is sometimes not possible to achieve total regional
anesthesia for incision and drainage of an abscess, perhaps
because local tissue acidosis neutralizes local anesthetics.
In such cases, additional analgesia may be obtained by
premedication with narcotics or brief inhalation of nitrous
- Llera JL, Levy RC: Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985;14:15-19.
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD