Cutaneous abscess: Difference between revisions
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An '''abscess''' is a collection of [[pus]] that has accumulated in a cavity formed by the tissue on the basis of an [[infection|infectious]] process (usually caused by [[bacterium|bacteria]] or [[parasite]]s) or other foreign materials (e.g. splinters or bullet wounds). It is a [[immune system|defensive reaction]] of the tissue to prevent the spread of infectious materials to other parts of the body. | An '''abscess''' is a collection of [[pus]] that has accumulated in a cavity formed by the tissue on the basis of an [[infection|infectious]] process (usually caused by [[bacterium|bacteria]] or [[parasite]]s) or other foreign materials (e.g. splinters or bullet wounds). It is a [[immune system|defensive reaction]] of the tissue to prevent the spread of infectious materials to other parts of the body. | ||
==Pathophysiology== | |||
The organisms or foreign materials kill the local [[cell (biology)|cell]]s, resulting in the release of [[toxin]]s. The toxins trigger an [[inflammation|inflammatory response]], which draws large numbers of [[white blood cell]]s to the area and increases the regional [[blood]] flow. | The organisms or foreign materials kill the local [[cell (biology)|cell]]s, resulting in the release of [[toxin]]s. The toxins trigger an [[inflammation|inflammatory response]], which draws large numbers of [[white blood cell]]s to the area and increases the regional [[blood]] flow. | ||
The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object. | The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object. | ||
==Differentiating Abscess from other Conditions== | |||
Abscesses must be differentiated from [[empyema]]s, which are accumulations of pus in a preexisting rather than a newly formed anatomical cavity. | Abscesses must be differentiated from [[empyema]]s, which are accumulations of pus in a preexisting rather than a newly formed anatomical cavity. | ||
== | ==Diagnosis== | ||
===History and Symptoms=== | |||
The cardinal symptoms and signs of any kind of inflammatory process are redness, heat, swelling, pain and loss of function. Abscesses may occur in any kind of solid tissue but most frequently on skin surface (where they may be superficial pustules ([[boil]]s) or deep skin abscesses), in the lungs, [[brain abscess|brain]], [[Tooth abscess|teeth]], kidneys and tonsils. Major complications are spreading of the abscess material to adjacent or remote tissues and extensive regional tissue death ([[gangrene]]). Abscesses in most parts of the body rarely heal themselves, so prompt medical attention is indicated at the first suspicion of an abscess. | The cardinal symptoms and signs of any kind of inflammatory process are redness, heat, swelling, pain and loss of function. Abscesses may occur in any kind of solid tissue but most frequently on skin surface (where they may be superficial pustules ([[boil]]s) or deep skin abscesses), in the lungs, [[brain abscess|brain]], [[Tooth abscess|teeth]], kidneys and tonsils. Major complications are spreading of the abscess material to adjacent or remote tissues and extensive regional tissue death ([[gangrene]]). Abscesses in most parts of the body rarely heal themselves, so prompt medical attention is indicated at the first suspicion of an abscess. | ||
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Wound abscesses do not generally need to be treated with antibiotics, but they will require surgical intervention, debridement and curretage.<ref>McLatchie G, Leaper D, (eds). 2007. Oxford Handbook of Clinical Surgery, 2nd ed. Oxford. OUP</ref> | Wound abscesses do not generally need to be treated with antibiotics, but they will require surgical intervention, debridement and curretage.<ref>McLatchie G, Leaper D, (eds). 2007. Oxford Handbook of Clinical Surgery, 2nd ed. Oxford. OUP</ref> | ||
===Incision and drainage=== | ===Medical Therapy=== | ||
====Antibiotics==== | |||
As ''[[Staphylococcus aureus]]'' [[bacteria]] is a common cause, an anti-staphylococcus antibiotic such as [[flucloxacillin]] or [[dicloxacillin]] is used. With the emergence of community-acquired methicillin-resistant staphylococcus aureus [[MRSA]], these traditional antibiotics may be ineffective; alternative antibiotics effective against community-acquired MRSA often include clindamycin, trimethoprim-sulfamethoxazole, and doxycycline. (However, if cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin.) It is important to note that [[antibiotic]] therapy alone ''without surgical drainage of the abscess'' is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low [[pH]] levels. | |||
====Recurrent infections==== | |||
Recurrent abscesses are often caused by community-acquired [[MRSA]]. While resistant to most beta lactam antibiotics commonly used for skin infections, it remains sensitive to alternative antibiotics, ie clindamycin (Cleocin), trimethoprim-sulfamethoxazole (Bactrim), and doxycycline (unlike hospital-acquired MRSA that may only be sensitive to vancomycin IV). | |||
To prevent recurrent infections due to ''[[Staphylococcus]]'', consider the following measures: | |||
*Topical [[mupirocin]] applied to the nares <ref name=Raz1996>{{cite journal | author = Raz R, Miron D, Colodner R, Staler Z, Samara Z, Keness Y | title = A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection. | journal = Arch Intern Med | volume = 156 | issue = 10 | pages = 1109-12 | year = 1996 | id = PMID 8638999}}</ref>. In this [[randomized controlled trial]], patients used nasal mupirocin twice daily 5 days a month for 1 year. | |||
*[[Chlorhexidine]] baths <ref name=Watanakunakorn>{{cite journal | author = Watanakunakorn C, Axelson C, Bota B, Stahl C | title = Mupirocin ointment with and without chlorhexidine baths in the eradication of Staphylococcus aureus nasal carriage in nursing home residents. | journal = Am J Infect Control | volume = 23 | issue = 5 | pages = 306-9 | year = 1995 | id = PMID 8585642}}</ref>, In a [[randomized controlled trial]], nasal recolonization with S. aureus occurred at 12 weeks in 24% of nursing home residents receiving mupirocin ointment alone (6/25) and in 15% of residents receiving mupirocin ointment plus chlorhexidine baths daily for the first three days of mupirocin treatment (4/27). Although these results did not reach [[statistical significance]], the baths are an easy treatment. | |||
====Magnesium Sulphate Paste==== | |||
Historically abscesses as well as boils and many other collections of pus have been treated via application of [[magnesium sulfate]] paste. This works by drawing the infected pus to the surface of the skin before rupturing and leaking out, after this the body will usually repair the old infected cavity. Magnesium sulphate is therefore best applied at night with a sterile dressing covering it, the rupture itself is not painful but the drawing up may be uncomfortable. Magnesium sulphate paste is considered a "home remedy" and is not necessarily an effective or accepted medical treatment. | |||
===Surgery=== | |||
====Incision and drainage==== | |||
{{main|Incision and drainage}} | {{main|Incision and drainage}} | ||
The abscess should be inspected to identify if foreign objects are a cause, requiring surgical removal. If foreign objects are not the cause, a doctor will incise and drain the abscess and prescribe painkillers and possibly antibiotics. | The abscess should be inspected to identify if foreign objects are a cause, requiring surgical removal. If foreign objects are not the cause, a doctor will incise and drain the abscess and prescribe painkillers and possibly antibiotics. | ||
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In critical areas where surgery presents a high risk, surgery may be delayed or used as a last resort. The drainage of a lung abscess may be performed by positioning the patient in a way that enables the contents to be discharged via the [[respiratory tract]]. Warm compresses and elevation of the limb may be beneficial for skin abscess. | In critical areas where surgery presents a high risk, surgery may be delayed or used as a last resort. The drainage of a lung abscess may be performed by positioning the patient in a way that enables the contents to be discharged via the [[respiratory tract]]. Warm compresses and elevation of the limb may be beneficial for skin abscess. | ||
===Primary closure=== | ====Primary closure==== | ||
Primary closure has been successful when combined with [[curettage]] and [[antibiotics]]<ref name="pmid9137156">{{cite journal |author=Abraham N, Doudle M, Carson P |title=Open versus closed surgical treatment of abscesses: a controlled clinical trial |journal=The Australian and New Zealand journal of surgery |volume=67 |issue=4 |pages=173-6 |year=1997 |pmid=9137156 |doi=}}</ref> or with curettage alone.<ref name="pmid3881155">{{cite journal |author=Stewart MP, Laing MR, Krukowski ZH |title=Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial |journal=The British journal of surgery |volume=72 |issue=1 |pages=66-7 |year=1985 |pmid=3881155 |doi=}}</ref> However, another [[randomized controlled trial]] found primary closure led to 35% failing to heal primarily and primary closure longer median number of days to closure (8.9 versus 7.8).<ref name="pmid6805714">{{cite journal |author=Simms MH, Curran F, Johnson RA, ''et al'' |title=Treatment of acute abscesses in the casualty department |journal=British medical journal (Clinical research ed.) |volume=284 |issue=6332 |pages=1827-9 |year=1982 |pmid=6805714 |doi=}}</ref> | Primary closure has been successful when combined with [[curettage]] and [[antibiotics]]<ref name="pmid9137156">{{cite journal |author=Abraham N, Doudle M, Carson P |title=Open versus closed surgical treatment of abscesses: a controlled clinical trial |journal=The Australian and New Zealand journal of surgery |volume=67 |issue=4 |pages=173-6 |year=1997 |pmid=9137156 |doi=}}</ref> or with curettage alone.<ref name="pmid3881155">{{cite journal |author=Stewart MP, Laing MR, Krukowski ZH |title=Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial |journal=The British journal of surgery |volume=72 |issue=1 |pages=66-7 |year=1985 |pmid=3881155 |doi=}}</ref> However, another [[randomized controlled trial]] found primary closure led to 35% failing to heal primarily and primary closure longer median number of days to closure (8.9 versus 7.8).<ref name="pmid6805714">{{cite journal |author=Simms MH, Curran F, Johnson RA, ''et al'' |title=Treatment of acute abscesses in the casualty department |journal=British medical journal (Clinical research ed.) |volume=284 |issue=6332 |pages=1827-9 |year=1982 |pmid=6805714 |doi=}}</ref> | ||
In anorectal abscesses, primary closure healed faster, but 25% of abscesses healed by secondary healing and recurrence was higher.<ref name="pmid6397949">{{cite journal |author=Kronborg O, Olsen H |title=Incision and drainage v. incision, curettage and suture under antibiotic cover in anorectal abscess. A randomized study with 3-year follow-up |journal=Acta Chirurgica Scandinavica |volume=150 |issue=8 |pages=689-92 |year=1984 |pmid=6397949 |doi=}}</ref> | In anorectal abscesses, primary closure healed faster, but 25% of abscesses healed by secondary healing and recurrence was higher.<ref name="pmid6397949">{{cite journal |author=Kronborg O, Olsen H |title=Incision and drainage v. incision, curettage and suture under antibiotic cover in anorectal abscess. A randomized study with 3-year follow-up |journal=Acta Chirurgica Scandinavica |volume=150 |issue=8 |pages=689-92 |year=1984 |pmid=6397949 |doi=}}</ref> | ||
= | ===Perianal abscess=== | ||
==Perianal abscess== | |||
[[Perianal abscesses]] can be seen in patients with for example [[inflammatory bowel disease]] (such as [[Crohn's disease]]) or [[diabetes]]. Often the abscess will start as an internal wound caused by ulceration or hard stool. This wound typically becomes infected as a result of the normal presence of feces in the rectal area, and then develops into an abscess. This often presents itself as a lump of tissue near the [[anus]] which grows larger and more painful with the passage of time. | [[Perianal abscesses]] can be seen in patients with for example [[inflammatory bowel disease]] (such as [[Crohn's disease]]) or [[diabetes]]. Often the abscess will start as an internal wound caused by ulceration or hard stool. This wound typically becomes infected as a result of the normal presence of feces in the rectal area, and then develops into an abscess. This often presents itself as a lump of tissue near the [[anus]] which grows larger and more painful with the passage of time. | ||
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* [http://www.nlm.nih.gov/medlineplus/ency/article/001353.htm MedlinePlus Medical Encyclopedia - Abscess] | * [http://www.nlm.nih.gov/medlineplus/ency/article/001353.htm MedlinePlus Medical Encyclopedia - Abscess] | ||
* [http://www.nlm.nih.gov/medlineplus/ency/article/000863.htm MedlinePlus Medical Encyclopedia - Skin Abscess] | * [http://www.nlm.nih.gov/medlineplus/ency/article/000863.htm MedlinePlus Medical Encyclopedia - Skin Abscess] | ||
{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
Revision as of 16:04, 22 August 2012
| Cutaneous abscess | |
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| Abscess | |
| ICD-9 | 682.9 |
| MeSH | D000038 |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
An abscess is a collection of pus that has accumulated in a cavity formed by the tissue on the basis of an infectious process (usually caused by bacteria or parasites) or other foreign materials (e.g. splinters or bullet wounds). It is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body.
Pathophysiology
The organisms or foreign materials kill the local cells, resulting in the release of toxins. The toxins trigger an inflammatory response, which draws large numbers of white blood cells to the area and increases the regional blood flow.
The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object.
Differentiating Abscess from other Conditions
Abscesses must be differentiated from empyemas, which are accumulations of pus in a preexisting rather than a newly formed anatomical cavity.
Diagnosis
History and Symptoms
The cardinal symptoms and signs of any kind of inflammatory process are redness, heat, swelling, pain and loss of function. Abscesses may occur in any kind of solid tissue but most frequently on skin surface (where they may be superficial pustules (boils) or deep skin abscesses), in the lungs, brain, teeth, kidneys and tonsils. Major complications are spreading of the abscess material to adjacent or remote tissues and extensive regional tissue death (gangrene). Abscesses in most parts of the body rarely heal themselves, so prompt medical attention is indicated at the first suspicion of an abscess.
Treatment
Wound abscesses do not generally need to be treated with antibiotics, but they will require surgical intervention, debridement and curretage.[1]
Medical Therapy
Antibiotics
As Staphylococcus aureus bacteria is a common cause, an anti-staphylococcus antibiotic such as flucloxacillin or dicloxacillin is used. With the emergence of community-acquired methicillin-resistant staphylococcus aureus MRSA, these traditional antibiotics may be ineffective; alternative antibiotics effective against community-acquired MRSA often include clindamycin, trimethoprim-sulfamethoxazole, and doxycycline. (However, if cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin.) It is important to note that antibiotic therapy alone without surgical drainage of the abscess is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low pH levels.
Recurrent infections
Recurrent abscesses are often caused by community-acquired MRSA. While resistant to most beta lactam antibiotics commonly used for skin infections, it remains sensitive to alternative antibiotics, ie clindamycin (Cleocin), trimethoprim-sulfamethoxazole (Bactrim), and doxycycline (unlike hospital-acquired MRSA that may only be sensitive to vancomycin IV).
To prevent recurrent infections due to Staphylococcus, consider the following measures:
- Topical mupirocin applied to the nares [2]. In this randomized controlled trial, patients used nasal mupirocin twice daily 5 days a month for 1 year.
- Chlorhexidine baths [3], In a randomized controlled trial, nasal recolonization with S. aureus occurred at 12 weeks in 24% of nursing home residents receiving mupirocin ointment alone (6/25) and in 15% of residents receiving mupirocin ointment plus chlorhexidine baths daily for the first three days of mupirocin treatment (4/27). Although these results did not reach statistical significance, the baths are an easy treatment.
Magnesium Sulphate Paste
Historically abscesses as well as boils and many other collections of pus have been treated via application of magnesium sulfate paste. This works by drawing the infected pus to the surface of the skin before rupturing and leaking out, after this the body will usually repair the old infected cavity. Magnesium sulphate is therefore best applied at night with a sterile dressing covering it, the rupture itself is not painful but the drawing up may be uncomfortable. Magnesium sulphate paste is considered a "home remedy" and is not necessarily an effective or accepted medical treatment.
Surgery
Incision and drainage
The abscess should be inspected to identify if foreign objects are a cause, requiring surgical removal. If foreign objects are not the cause, a doctor will incise and drain the abscess and prescribe painkillers and possibly antibiotics.
Surgical drainage of the abscess (e.g. lancing) is usually indicated once the abscess has developed from a harder serous inflammation to a softer pus stage. This is expressed in the Latin medical aphorism Ubi pus, ibi evacua.
In critical areas where surgery presents a high risk, surgery may be delayed or used as a last resort. The drainage of a lung abscess may be performed by positioning the patient in a way that enables the contents to be discharged via the respiratory tract. Warm compresses and elevation of the limb may be beneficial for skin abscess.
Primary closure
Primary closure has been successful when combined with curettage and antibiotics[4] or with curettage alone.[5] However, another randomized controlled trial found primary closure led to 35% failing to heal primarily and primary closure longer median number of days to closure (8.9 versus 7.8).[6]
In anorectal abscesses, primary closure healed faster, but 25% of abscesses healed by secondary healing and recurrence was higher.[7]
Perianal abscess
Perianal abscesses can be seen in patients with for example inflammatory bowel disease (such as Crohn's disease) or diabetes. Often the abscess will start as an internal wound caused by ulceration or hard stool. This wound typically becomes infected as a result of the normal presence of feces in the rectal area, and then develops into an abscess. This often presents itself as a lump of tissue near the anus which grows larger and more painful with the passage of time.
Like other abscesses, perianal abscesses may require prompt medical treatment, such as an incision and debridement or lancing.
See also
References
- ↑ McLatchie G, Leaper D, (eds). 2007. Oxford Handbook of Clinical Surgery, 2nd ed. Oxford. OUP
- ↑ Raz R, Miron D, Colodner R, Staler Z, Samara Z, Keness Y (1996). "A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection". Arch Intern Med. 156 (10): 1109–12. PMID 8638999.
- ↑ Watanakunakorn C, Axelson C, Bota B, Stahl C (1995). "Mupirocin ointment with and without chlorhexidine baths in the eradication of Staphylococcus aureus nasal carriage in nursing home residents". Am J Infect Control. 23 (5): 306–9. PMID 8585642.
- ↑ Abraham N, Doudle M, Carson P (1997). "Open versus closed surgical treatment of abscesses: a controlled clinical trial". The Australian and New Zealand journal of surgery. 67 (4): 173–6. PMID 9137156.
- ↑ Stewart MP, Laing MR, Krukowski ZH (1985). "Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial". The British journal of surgery. 72 (1): 66–7. PMID 3881155.
- ↑ Simms MH, Curran F, Johnson RA; et al. (1982). "Treatment of acute abscesses in the casualty department". British medical journal (Clinical research ed.). 284 (6332): 1827–9. PMID 6805714.
- ↑ Kronborg O, Olsen H (1984). "Incision and drainage v. incision, curettage and suture under antibiotic cover in anorectal abscess. A randomized study with 3-year follow-up". Acta Chirurgica Scandinavica. 150 (8): 689–92. PMID 6397949.