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11.10 Cutaneous Abscess or Pustule


Presentation

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:

What not to do:

Discussion

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 oxide.

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