Introduction to Incision and Drainage

• I+D is the primary therapy for the management of cutaneous abcesses
• Most localized skin abscesses can be managed with simple I+D and do not require antibiotics
• General anaesthetic (GA) is required for large abscesses requiring extensive incision, debridemenet or irrigation. Also deep abscesses in sensitive areas (supralevator, ischiorectal, perirectal) require GA for proper exposure

Preparation

An appropriately consented and anaesthetized patient should be draped in order to expose the abscess.
If EUA is required then the patient should be placed in the lithotomy position.

Procedure

• Incision - can be elliptical or cruciate and should be made over the most fluctuant point of the abscess.
• Deroof abscess - remove skin (and any necrotic tissue) in order to leave a hole overlying the abscess.
• Pus swab - take a swab from deep within the abscess and send off for microscopy, sensitivity and culture.
• Explore the abscess cavity - use your finger or a curette to break down all loculi and evacuate as much of the pus as possible.
• Irrigation - now you can wash out the abscess cavity using a large amount of normal saline. There is no evidence to support the use of one form of irrigation solution over another. The important thing is to use lots of irrigation.
• Haemostasis - pressure alone should stop any bleeding. If you can see an obvious point of bleeding you can use diathermy.
• Pack - loosely pack the abscess cavity from the bottom up using kaltostat or gauze making sure the opening in the skin remains wider than the base which should allow it to granulate from the bottom up. There are not any studies that compare different packing materials but loose packing is important to avoid significant discomfort and difficulty in changing dressings.

Post-op

• Routine observation of heart rate, blood pressure and temperature
• The patient can go home the same evening or the next day ¹
• Daily dressing change (by district nurse if necessary) until the packs become dry
• Antibiotics are not usually required. Treatment with I+D alone leads to resolution without complications at the same rate (>90%) as patients treated with I+D and antibiotics ^1,2
• Takes approximately 4 - 6 weeks to heal

1. 1) A Hankin, L Everett et al. Are antibiotics Necessary after Incision and Drainage of A Cutaneous Abscess? Annals of Emergency Medicine. 2007; 6: 232-4
2. 2) M Paydar, K J Hansen, F Charlebois et al. Inappropriate Antibiotic Use In Soft Tissue Infections. Arch Surgery. 2007; 141: 850-56