How to loop drain a large skin abscess

Occasionally, patients will come to see you after enduring several days of pain and swelling from a skin abscess. If the abscess is over 5 cm, it is recommended to use the loop drainage technique.

With this technique, you only make two smaller incisions. The patient has less pain and the wound heals faster.

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

1. Your patient has a prosthetic heart valve or other risk factor(s) 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 large or deep. In these cases, you may need to take the procedure to the operating room.

The first step for the incision and drainage technique is to 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
• Extra glove and scissors

1. Gently clean the skin with a sterilizing solution.
2. Apply ice to the abscess.
3. Anesthetize the skin with lidocaine and epinephrine. The numb area will blanch within the next two minutes.
4. Make a stab incision on one side of the abscess.
5. Stick your hemostat through the abscess and break up loculations. Bring the tip of the probe near the second wheal of lidocaine you had previously made.
6. Now, make your second stab incision to reach the tip of the hemostat.
7. Guide the band through the first incision and grab the loop and pull it through the second incision.
8. Tie a knot in the band.

The loop keeps the track open and prevents the incision from closing too early. This way, the abscess keeps draining the pus until healed.

Place a dressing over the loop to absorb all the pus that will continue to drain. When the patient returns in a couple of days, you can cut the loop and remove it if the drainage has stopped.

Patients with abscesses over 5 cm should be treated with antibiotics. The choice of antibiotic of course depends on the bacteria in the abscess. It is almost always community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA).

Wound cultures aren’t necessary unless there are unusual features, such as sepsis, rapid progression, or concerns for clostridial infection.

Excellent work! You now know the basic diagnosis and treatment for large skin abscesses.

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