How to drain a small skin abscess

Siamak Moayedi, MD
22nd Jan 2021

What is a small, uncomplicated skin abscess?

There are several noticeable markers of a small, uncomplicated skin abscess: 

  1. Abscess is less than 5 cm in size. 
  2. Patient does not have a fever. 
  3. No surrounding cellulitis. 
  4. Patient is not immunocompromised (e.g., AIDS, chemotherapy, poorly controlled diabetes, immunotherapy-like transplant medicines, or chronic steroids).

Multi-component image of 5 cm circle, thermometer, crossed out cellulitis, and immunocompetent patient. Cartoon.

Figure 1. Markers of a small uncomplicated skin abscess include an abscess less than 5 cm in size in a patient who has no fever, no surrounding cellulitis, and is not immunocompromised.

Complicated abscesses will need antibiotics and sometimes even hospitalization.

 

Indications for abscess drainage

Incision and drainage is the definitive treatment for soft tissue abscesses. Antibiotics alone cannot effectively penetrate the abscess, and may not work in the acidic environment within the abscess. As well, draining the abscess results in immediate pain relief by decreasing pressure on the skin’s nerve fibers.

 

Relative contraindications for abscess drainage

There are four major scenarios where you should be careful about performing an incision and drainage: 

  1. Your patient has a prosthetic heart valve or other risk factors for developing endocarditis. In these cases, give the patient antibiotics before the procedure. 
  2. The abscess is near a vital structure (e.g., major blood vessel, nerve, or gland). In these cases, be careful about the depth of your incision. If you don’t feel comfortable, defer to a surgeon. 
  3. The abscess is located on a cosmetically significant area of the body (e.g., face or breast). In these cases, be careful about the size of your incision. 
  4. The abscess is large or deep. In these cases, you may need to take the procedure to the operating room.

Multi-component image of a heart, vital structures, face abscess, and large abscess. Cartoon.

Figure 2. Relative contraindications for an abscess drainage include prosthetic heart values or risk factors for developing endocarditis, abscess near a vital structure, abscess on a cosmetically significant area, and large and deep abscess. 

 

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Identifying the tools for an abscess drainage

Before you do an incision and drainage of an abscess, first collect the necessary medication and tools: 

  • Skin sterilizing solution
  • 1% lidocaine with epinephrine
  • 3 cc syringe and a 25 gauge (G) needle
  • #11 scalpel 
  • Hemostat
  • Gauze
  • Tape

Multi-component image of sterilizing solution, 1% lidocaine with epinephrine, syringe, needle, scalpel, hemostat, gauze, and tape. Cartoon.

Figure 3. The necessary medication and tools for small, uncomplicated abscess drainage include sterilizing solution, 1% lidocaine with epinephrine, 3 cc syringe and a 25 gauge (G) needle, #11 scalpel, hemostat, gauze, and tape. 

 

How to drain a small skin abscess

Now, let’s crack this abscess open! This step-by-step procedure ensures a safe, clean, and (relatively) painless abscess drainage: 

  1. Gently clean the skin with a sterilizing solution. 
  2. Apply ice to the abscess. Anesthetize the skin with lidocaine and epinephrine. The numb area will blanch within the next two minutes. 
  3. When the skin is numb (abscess appears blanched), make a 1–2 cm incision along the natural folds of the skin.
  4. Apply gentle pressure around the abscess to get as much of the pus out as possible. 
  5. If the wound is deep, take the hemostat and gently probe the wound to break up loculations. 
  6. Take a culture of the wound if you anticipate poor wound healing (e.g., in an immunocompromised patient). Generally, most abscesses are caused by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). 
  7. Place a dressing, but do not pack the wound (packing the wound been shown to delay healing and cause more pain). There is also no need for irrigation of the abscess cavity. 

Multi-component image of sterilizing bottle, ice, anesthetics, small incision, pus removal, hemostat, wound culture, and bandage. Cartoon.

Figure 4. Procedure for draining a small skin abscess. 1) Sterilize the skin. 2) Apply ice and anesthetize the area with lidocaine. 3) Make a 1–2 cm incision on the skin. 4) Apply pressure to remove pus. 5) Use hemostat to break up loculations. 6) Take a wound culture if you anticipate poor healing. 7) Place a dressing.  

The final decision to make is about antibiotics. In general, if it is an uncomplicated, small abscess, incision and drainage is the only treatment needed.

 

Post-procedure care for a skin abscess

Before sending the patient home, give them some dressing supplies and ask them to the keep the abscess clean and dry by changing the dressing twice a day. 

As well, instruct your patient to come back if they develop surrounding cellulitis, increasing pain, or fever. Either way, it’s a good idea to have them come back for a follow-up visit in two days.

Multi-component image of cellulitis, female patient in pain, and fever. Cartoon.

Figure 5. Post-procedure care includes instructing your patient to come back in the case of cellulitis, increasing pain, or fever.

 

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Recommended reading

  • Thompson, DO. 2014. Loop drainage of cutaneous abscesses using a modified sterile glove: a promising technique. J Emerg Med. 47: 188–191. PMID: 24928539
  • Tsoraides, S, Pearl, RH, Stanfill, AB, et al. 2010. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg45: 606–609. PMID: 20223328