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Skin abscesses, furuncles, and carbuncles

Author
Larry M Baddour, MD, FIDSA
Section Editors
Daniel J Sexton, MD
Morven S Edwards, MD
Deputy Editor
Elinor L Baron, MD, DTMH
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2016. | This topic last updated: Mar 16, 2016.

INTRODUCTION — Skin abscesses are collections of pus within the dermis and deeper skin tissues. A
furuncle (or "boil") is an infection of the hair follicle in which purulent material extends through the dermis
into the subcutaneous tissue, where a small abscess forms. A carbuncle is a coalescence of several
inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles (picture 1)
[1].

Most abscesses are caused by infection. However, sterile abscesses can occur in the setting of injected
irritants. Examples include injected drugs (particularly oil-based ones) that may not be fully absorbed and
so remain at the site of injection, causing local irritation. Sterile abscesses can turn into hard, solid lesions
as they scar.

The epidemiology, clinical manifestations, microbiology, and treatment of skin abscesses, furuncles, and
carbuncles due to infection will be reviewed here

RISK FACTORS — Skin abscesses, furuncles, and carbuncles can develop in healthy individuals with no
predisposing conditions other than skin or nasal carriage of Staphylococcus aureus; spontaneous
infection due to community-acquired methicillin-resistant S. aureus (CA-MRSA) may occur with greater
frequency than abscesses due to other pathogens [2]. Rectal colonization of S. aureus, including CA-
MRSA of the USA300 clone, was strongly associated with skin abscess formation in one pediatric
investigation [3].

Individuals in close contact with others who have active infection with skin abscesses, furuncles, and
carbuncles are at increased risk [4,5]. Individuals exposed to whirlpool footbaths at nail salons are at risk
for mycobacterial furunculosis [6,7]. Additional risk factors include diabetes mellitus and immunologic
abnormalities [6,8].

Any process leading to a breach in the skin barrier can also predispose to the development of a skin
abscesses, furuncle, or carbuncle. Examples include primary dermatologic conditions as well as trauma
related to abrasions, shaving, and insect bites. In addition, intravenous drug users are at particular risk
due to needle injection, including either intravenous injection or subcutaneous and intramuscular injection
("skin popping") [9-11].
CLINICAL MANIFESTATIONS

Skin abscesses — Skin abscesses are collections of pus within the dermis and deeper skin tissues. Skin
abscesses manifest as painful, tender, fluctuant, and erythematous nodules, frequently surmounted by a
pustule and surrounded by a rim of erythematous swelling (picture 2) [12]. Spontaneous drainage of
purulent material may occur, and regional adenopathy may be observed, although ascending
lymphangitis is not seen. Fever, chills, and systemic toxicity are unusual.

Skin abscess may arise as a result of bacteremia, and bacteremia may arise as result of skin abscess.
Sequelae of bacteremia related to skin abscess include metastatic sites of infection such as endocarditis
and osteomyelitis.

Ultrasound may be useful for distinguishing skin abscesses from other lesions [13].

Furuncles and carbuncles — A furuncle (or "boil") is an infection of the hair follicle in which purulent
material extends through the dermis into the subcutaneous tissue, where a small abscess forms.
Furuncles can occur anywhere on hairy skin and usually follow an episode of folliculitis. A carbuncle is a
coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from
multiple follicles (picture 1). Systemic symptoms are more common in the setting of carbuncles than
furuncles.

Furuncles and carbuncles arise when areas of skin containing hair follicles are exposed to friction and
perspiration. Common areas of involvement include the back of the neck, face, axillae, and buttocks.

Rarely, infections involving the medial third of the face (ie, the areas around the eyes and nose) can be
complicated by septic cavernous thrombosis, since the veins in this region are valveless (figure 1).

Differential diagnosis — Other skin lesions that should be distinguished from skin abscesses, furuncles,
and carbuncles include:

●Folliculitis
●Hidradenitis suppurativa
●Sporotrichosis
●Leishmaniasis
●Tularemia
●Myiasis
●Botryomycosis
●Nontuberculous mycobacteria
●Blastomycosis

Skin lesions in immunocompromised individuals should prompt consideration of additional pathogens

including Nocardia and Cryptococcus.

MICROBIOLOGY — Skin abscesses can be due to one or more than one pathogen and may include skin
flora as well as organisms from adjacent mucous membranes [12,14-16]. S. aureus monoinfection (either
methicillin-susceptible or methicillin-resistant S. aureus) occurs in up to 75 percent of cases [1,12,17-20].
Furuncles and carbuncles are usually attributable to S. aureus; culprits include both methicillin-
susceptible and methicillin-resistantS. aureus [21-23].
Isolates of S. aureus capable of producing Panton-Valentine leukocidin are associated with severe
infection; this is discussed further separately.

Isolation of multiple organisms (including gram negatives and anaerobes) is more common in patients
with skin abscess involving the perioral, perirectal, or vulvovaginal areas [12]. Organisms of oral origin,
including anaerobes, are seen most frequently among intravenous drug users [12].

Additional pathogens implicated in folliculitis can cause furuncles and carbuncles, given that all three
syndromes are related to hair follicle involvement. Such pathogens include Pseudomonas, Candida spp,
and others. Individuals exposed to whirlpool footbaths at nail salons are at risk for mycobacterial
furunculosis [6,7].

TREATMENT

Incision and drainage — For small furuncles, warm compresses to promote drainage are usually
sufficient treatment. Larger furuncles, carbuncles, and abscesses require incision and drainage, and
material should be sent for culture and susceptibility testing [24]. Although cultures were not obtained
routinely prior to the emergence of methicillin-resistant S. aureus (MRSA), the microbiology data are
important for both clinicians and epidemiologists to guide antimicrobial therapy, prevention, and control
measures.

Individuals at risk for endocarditis should receive antimicrobial prophylaxis prior to incision and drainage
[25,26]. If possible, vancomycin (1 g intravenously 60 minutes before the procedure) is preferred; if
intravenous administration is not feasible, a single dose of an oral agent with activity against MRSA is
acceptable (table 1 and table 2).

Role of antibiotics — The role of antimicrobial therapy for treatment of skin abscesses, furuncles, and
carbuncles depends on individual clinical circumstances [27]. In general, antibiotic therapy (in addition to
incision and drainage) is warranted for patients in any of the following categories [1,28-30]:

●Multiple lesions or single abscess ≥2 cm

●Extensive surrounding cellulitis
●Associated comorbidities or immunosuppression
●Signs of systemic infection
●Inadequate clinical response to incision and drainage alone
●Presence of an indwelling medical device (such as prosthetic joint, vascular graft, or pacemaker)
●High risk for transmission of S. aureus to others (such as in athletes, military personnel)

Management with incision and drainage alone (in the absence of antimicrobial therapy) is generally
sufficient for otherwise healthy patients with skin abscess <2 cm in the absence of the above factors
[17,31,32]. This approach may also be reasonable for patients with skin abscess ≥2 cm in the setting of
multiple antibiotic allergies or intolerances.

The above approach to use of antibiotics is supported by findings of a randomized trial including 1220
patients >12 years of age (median 35 years) with drained skin abscess (≥2 cm in diameter) treated with
TMP-SMX (320mg/1600 mg twice daily) or placebo, the cure rate 7 to 14 days after treatment was higher
among who received TMP/SMX (80.5 versus 73.6 percent); wound cultures were positive for MRSA in 45
percent of cases [33]. Use of incision and drainage alone (in the absence of antimicrobial therapy) is
supported by findings of a randomized trial including 212 patients treated with TMP-SMX or placebo;
TMP-SMX did not reduce the likelihood of treatment failure [32], although the trial was underpowered
[34]. Another trial included 166 adults with skin abscesses who underwent incision and drainage and
were subsequently randomized to cephalexin or placebo; among the 85 patients with MRSA-positive
cultures, cure rates were comparable for both groups (84 and 90 percent, respectively) [17].

It is uncertain whether antimicrobial therapy decreases the risk of recurrent infection. Two randomized
trials (one that included adults and one that included children) demonstrated the likelihood of recurrent
abscess formation was lower in patients who received TMP-SMX than in patients who received placebo
[32,35].

Antibiotic selection — Empiric antibiotic therapy for skin abscesses, furuncles, and carbuncles should
include activity against MRSA in areas of high MRSA prevalence (table 3). Patients with localized disease
who appear otherwise well may be managed as outpatients with oral therapy; appropriate oral agents are
shown in the Table (table 2). Empiric therapy selection should be tailored to culture and susceptibility
results when available. In cases due to methicillin-susceptible S. aureus (MSSA), treatment consists
of dicloxacillin (500 mg orally every six hours) or cephalexin (500 mg orally every six hours).

Patients with evidence of extensive skin involvement or systemic toxicity should receive parenteral
antimicrobial therapy that includes empiric coverage for gram-positive pathogens including MRSA as well
as gram-negative and anaerobic organisms, pending culture and susceptibility results. The appropriate
initial choice for parenteral treatment of MRSA is vancomycin; alternative parenteral agents with activity
against MRSA for adults are shown in the Table (table 1) and discussed in detail separately. Options for
gram-negative and anaerobic coverage are outlined in the Table (table 4). Parenteral agents for children
are discussed separately.

The duration of antimicrobial therapy should be tailored to clinical improvement; about five to seven days
is usually sufficient. Longer duration of therapy may be warranted for patients with severe disease; in
such cases, duration should be tailored to clinical resolution of symptoms. Patients treated initially with
parenteral therapy with resolving signs of infection may complete antimicrobial therapy with an oral agent.

RECURRENT INFECTION — Recurrent infection may occur as a result of recurrent epidemiologic

risk and/or host immunosuppression. Preventive measures for reducing the spread of staphylococci may
be helpful for reducing risk for recurrent skin infection and are discussed in detail separately.

Immunosuppression predisposing to recurrent skin infection may be inherited or acquired. Inherited

conditions are discussed in detail separately. Patients with risk factors for acquired immunosuppressive
conditions predisposing to infection (such as diabetes or HIV infection) should undergo screening for
these conditions.

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●Basics topic

SUMMARY AND RECOMMENDATIONS

●Skin abscesses are collections of pus within the dermis and deeper skin tissues. They manifest as
painful, tender, fluctuant, and erythematous nodules, frequently surmounted by a pustule and
surrounded by a rim of erythematous swelling. (See 'Clinical manifestations' above.)
●A furuncle is an infection of the hair follicle in which purulent material extends through the dermis
into the subcutaneous tissue, where a small abscess forms. A carbuncle is a coalescence of several
inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles.
(See 'Clinical manifestations' above.)
●Risk factors for developing skin abscesses, furuncles, and carbuncles include diabetes mellitus,
immunologic abnormalities, and breaches to the skin barrier. However, healthy individuals with no
risk factors may also develop these infections. (See 'Risk factors' above.)
●Skin abscesses, furuncles, and carbuncles may be polymicrobial or
monomicrobial. Staphylococcus aureus infection occurs in up to 75 percent of cases.
(See 'Microbiology' above.)
●For small furuncles, warm compresses to promote drainage are usually sufficient treatment.
(See 'Treatment' above.)
●We recommend that patients with skin abscesses, larger furuncles, and carbuncles undergo
incision and drainage (Grade 1C). Debrided material should be sent for culture and susceptibility
testing. (See 'Incision and drainage' above.)
●The role of antimicrobial therapy for treatment of skin abscesses, larger furuncles, and carbuncles
depends on individual clinical circumstances. In general, we recommend antibiotic therapy for
patients with multiple lesions, extensive surrounding cellulitis, associated comorbidities or
immunosuppression, signs of systemic infection, or inadequate clinical response to incision and
drainage alone (Grade 1A), and we suggest antibiotic therapy for patients with skin abscess ≥2 cm,
an indwelling device, or high risk for transmission of S. aureus to others (Grade 2B). For otherwise
healthy patients with none of the above factors, we suggest not administering antimicrobial therapy
(Grade 2B). (See 'Role of antibiotics' above.)
●Antibiotic selection and duration of therapy is as outlined above. (See 'Antibiotic selection' above.)
●Preventive measures for reducing the spread of staphylococci may be helpful for reducing risk for
recurrent skin abscesses and are discussed in detail separately.

REFERENCES

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skin abscesses in the pediatric patient. Ann Emerg Med 2010; 55:401.
32. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin
abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010;
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33. Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N
Engl J Med 2016; 374:823.
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Topic 7656 Version 25.0

GRAPHICS

Carbuncle

Carbuncle, which is a series of abscesses in the subcutaneous tissue that drain via hair follicles.

Reproduced with permission from: Berg D, Worzala K. Atlas of Adult Physical Diagnosis. Philadelphia: Lippincott Williams & Wilkins,

2006. Copyright © 2006 Lippincott Williams & Wilkins.

Graphic 70089 Version 3.0

Skin abscess

Courtesy of Larry M Baddour, MD.

Graphic 53261 Version 1.0

Central triangle of the face

Rarely, infections involving the medial third of the face (ie, the areas around the eyes and
nose) can be complicated by septic cavernous thrombosis, since the veins in this region are valveless.
Graphic 55404 Version 4.0
Contributor Disclosures

Larry M Baddour, MD, FIDSA Nothing to disclose. Daniel J Sexton, MD Grant/Research/Clinical Trail
Support: Centers for Disease Control and Prevention; National Institutes of Health [Healthcare
epidemiology]. Consultant/Advisory Boards: Sterils [Medical waste disposal]. Equity Ownership/Stock
Options: Magnolia Medical Technologies [Medical diagnostics (Blood culture techniques)]. Other
Financial Interest: Johnson & Johnson [Mesh-related infections (Mesh grafts)]. Morven S Edwards,
MD Grant/Research/Clinical Trial Support: Pfizer Inc. [Group B Streptococcus]. Elinor L Baron, MD,
DTMH Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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