Incision and Drainage

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17 Incision and Drainage

Daniel L. Stulberg, MD, and Patrick Moran, DO

Incision and drainage (I&D) is a simple in-office procedure that in most cases is curative for superficial abscesses and related infections including uncomplicated methicillin-resistant Staphylococcus aureus (MRSA) abscesses. Commonly, patients will present with the acute onset of localized pain, swelling, and erythema indicating abscess formation (Figure 17-1). These can be the result of trauma, injection drug use, insect stings or bites, a secondary infection or inflammation of an epidermoid cyst, or paronychia from nail biting or manipulation, or they may arise without a clear inciting event.

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FIGURE 17-1 Abscess with raised fluctuant center on the arm.

(Copyright Richard P. Usatine, MD.)

The most common pathogens are Staphylococcus aureus and Streptococcus bacteria. Systemic antibiotics should usually only be given if there is surrounding cellulitis (Figure 17-2) or other signs or symptoms of further infection. There is no clear need for antibiotics even if localized MRSA is present, and there is also no clear indication for antibiotics in a patient with diabetes or an immune-compromised patient as long as the infection is a localized one that can be drained.1,2 Some patients may be colonized with MRSA and develop recurrent abscesses. In this situation, treatment with systemic antibiotics such as trimethoprim/sulfamethoxazole, doxycycline, or clindamycin based on local sensitivity patterns may help. Mupirocin is applied inside the nares twice daily for 5 days and topical chlorhexidine skin washing is commonly used to try to clear the carrier state, although the literature does not clearly support these practices.3,4

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FIGURE 17-2 Abscess with cellulitis. Note the erythema around this breast abscess. This presentation prompted an investigation for underlying breast cancer.

(Copyright Richard P. Usatine, MD.)

Indications

The following lesions should be treated with incision and drainage:

• Abscess
• Abscessed epidermoid cyst
• Furuncle—abscess related to the hair follicle
• Carbuncle—coalescence of furuncles
• Paronychia—abscess at the nail margin.

Contraindications and Cautions

• This chapter deals with superficial abscesses seen in routine office practice. Deep abscesses and those of body compartments including the palm of the hand require more extensive surgical intervention.
• Perirectal abscesses should be approached cautiously. They may be associated with deep disease or underlying inflammatory bowel disease and care should be taken not to damage the anal sphincter, which can cause incontinence.5
• Incision and drainage of abscesses of the face can lead to scarring, so choose the line of incision along skin tension lines, wrinkles, or other structures to minimize the prominence of the scar. Needle aspiration and antibiotics can be tried as initial treatment with close follow-up and an informed patient understanding that incision and drainage may ultimately be necessary.
• Be cautious to avoid damage to underlying structures including nerves and blood vessels.
• Abscesses and infections in closed spaces including the hand, foot, and orbits require additional intervention and consultation.
• Crepitus or gas seen on imaging suggests a more serious infection such as necrotizing fasciitis. This is a surgical emergency requiring a STAT surgical consult.
• Breast abscesses in a nonlactating woman should prompt evaluation for possible cancer (Figure 17-2).
• Abscesses of the central face in the “danger triangle” between the bridge of the nose and the angles of the mouth may lead to further complications such as a cavernous sinus thrombosis. These are best treated with antibiotics and warm compresses early to prevent a cavernous sinus thrombosis.6

Advantages of Incision and Drainage

The advantages of I&D can be categorized into those for the clinician and those for the patient. Advantages for the clinician include the following:

• Patient results are usually excellent.
• The procedure is simple to perform.
• Most are amenable to being performed in the office setting.

 

Advantages for the patient include:

• Results are usually excellent.
• Reduction in pain may occur quickly.
• This is an office procedure that can save a patient the higher copays and bills that result from an emergency department or surgical center visit.
• Family member or friend can be instructed to do the repacking when needed.

Disadvantages Of Incision And Drainage

As with the advantages of I&D, the disadvantages can also be categorized into those for the clinician and those for the patient. Disadvantages for the clinician include the following:

• Time to collect supplies and perform the procedure
• Possibility of body fluid exposure.

 

Disadvantages for the patient include:

• Pain of procedure
• Scarring.

Equipment

• Alcohol, povidone-iodine, and/or chlorhexidine for skin preparation
• Lidocaine, plain or with epinephrine
• Ethyl chloride spray (This is an optional topical anesthesia that is used to drain a paronychia or prior to a lidocaine injection.)
• 3- to 10-mL syringe based on size of abscess
• 18-gauge or large needle to draw up anesthesia
• 27-gauge 1.5-inch needle for anesthesia injections
• Clean gloves
• No. 11 blade with disposable or nondisposable scalpel handle
• Hemostat (Many clinicians prefer a curved hemostat to more easily get to loculations.)
• Scissors
• 4 × 4 gauze pads
• Ribbon gauze, image or image inch depending on lesion size
• Culture swab and transport media if desired
• Dressing 4 × 4 gauze or nonadherent dressing and tape, or large adhesive dressing.

 

Some clinicians also use the following:

• Sterile saline for irrigation
• Irrigation syringe and catheter, or angiocath with the needle removed.

Incision and Drainage: Steps and Principles

1. Counsel the patient regarding the diagnosis of abscess and that the recommended treatment is incision and drainage followed by packing with gauze. Obtain informed consent verbally and in writing.
2. Abscesses tend to be more difficult to anesthetize than routine lesions because the acidic environment caused by the bacteria does not respond as well to lidocaine. After prepping the skin with alcohol, inject 1% lidocaine with epinephrine to start the process. One method is to use a fan pattern lateral to one side of the abscess then lateral to the other side of the lesion and underneath the lesion (Figure 17-3). A ring block is also commonly used for an abscess (see Figure 3-11 in Chapter 3, Anesthesia). Avoid injecting into the abscess itself, because that will increase pressure and pain and may cause the abscess to spontaneously rupture under pressure, spraying out its contents and increasing the risk of exposure to care providers. For this reason and because the lesion may already be under pressure, proper eye and barrier protection is recommended. A full face shield (e.g., the Splash Shield as seen in Figure 2-14 of Chapter 2) and a disposable gown provide good protection in this setting.
3. While the anesthetic is taking effect, set up the rest of the instruments listed above. Clean gloves and a clean technique are used. Open the bottle of strip gauze and using the forceps pick up the end and extract a length of gauze that will be more than enough to pack into the abscess cavity. Cut the strip with the scissors just above the bottle and the end will fall back cleanly into the bottle. Some clinicians use iodoform gauze to pack abscesses. This author uses plain gauze because it seems to cause less burning discomfort, and iodine even in dilute concentrations is toxic to new tissue growth.
4. In cosmetically sensitive areas, and whenever possible, align the incision along the normal skin tension lines or along structures where the scar will be less visible after healing. Using the No. 11 blade perpendicular to the skin, incise the lesion at the area of “pointing” if present where the skin has already thinned out and the purulence can be seen through the skin (Figure 17-4). Extend the incision to allow adequate exploration, drainage, and packing.
5. The pus will usually spontaneously drain (Figure 17-5) or may spray out under pressure. Express the remaining purulent material by compressing toward the abscess from both sides with gauze in hands (Figure 17-6).
6. Use the hemostats to explore the cavity and break up any loculations (Figure 17-7). If the abscess is from an inflamed or infected epidermoid cyst, use the hemostat to pull out visible portions of the cyst wall to try and prevent recurrence. Then express any remaining purulence.
7. Use cotton-tipped applicators (CTAs) to explore the cavity and clean out remaining bits of infected tissue and purulence.
8. Some clinicians will irrigate at this stage with sterile saline (Figure 17-8). This is a common practice, but a literature review found no concrete evidence to support the practice.7
9. Using the forceps (without teeth works better) grasp the strip gauze and start packing it into the deepest portion of the abscess cavity (Figure 17-9). Using the stick end of a CTA can help when pushing the gauze into the cavity. Continue to pack the gauze until the cavity is full and then leave a 3- to 4-cm tail outside of the wound to facilitate later removal.
10. Cover the gauze tail with gauze or a nonadherent dressing and tape. Ask the patient to keep the dressing dry for 48 hours.
11. If no further packing will be needed, show the patient how to remove the strip gauze in 2 days at home. Often this may be done in the shower. If the patient cannot reach the gauze then help will be needed.
12. If the follow-up is done in 2 days, grasp the tail of the strip gauze and in one long swift movement remove the entire strip of gauze. This is painful, but preferable to prolonging the discomfort of tugging out the gauze inch by inch.
image

FIGURE 17-3 Injecting laterally and deep to the abscess for anesthesia.

(Copyright Richard P. Usatine, MD.)

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FIGURE 17-4 Incising the abscess.

(Copyright Daniel L. Stulberg, MD.)

image

FIGURE 17-5 Release of pus.

(Copyright Daniel L. Stulberg, MD.)

image

FIGURE 17-6 Expressing the purulent material.

(Copyright Daniel L. Stulberg, MD.)

image

FIGURE 17-7 Breaking up loculations.

(Copyright Daniel L. Stulberg, MD.)

image

FIGURE 17-8 Irrigating the abscess cavity.

(Copyright Daniel L. Stulberg, MD.)

image

FIGURE 17-9 Packing the abscess cavity with strip gauze.

(Copyright Daniel L. Stulberg, MD.)

Aftercare

Repacking can be done during office visits or at home if a reliable friend or family member is available to help. Repacking is uncomfortable, but usually tolerable without anesthetic.

There are no RCTs to inform us on how often and for how long a healing abscess should be packed.8 A small abscess can often be packed only once at the time of the I&D and then the patient can be directed to remove the packing at home in 2 days. A very large abscess may need repacking every other day for 1 to 2 weeks. Consider that each time an abscess is unpacked and repacked, it causes pain to the patient. Also the packing will delay the ultimate healing but may be needed when there is a risk that premature closure will allow a new abscess to form. Therefore, the decision on how often and how long an abscess is packed is based on physician experience, patient preferences as well as size and location.

Paronychia

Paronychia is a local bacterial infection of the nail fold. These infections are often caused by nail biting or manipulating the nail or nail margins (Figure 17-10). Prior to opening the abscess the paronychia can be locally anesthetized with ethyl chloride spray. It is important to be ready to make the cut in the paronychia quickly because the anesthetic effect is very brief. A No. 11 scalpel can be used to incise the abscess at the nail margin (Figure 17-11). These lesions are usually too small to allow packing. In more severe cases, a digital block or lidocaine injected locally may be needed. Counsel the patient to use warm soaks three times a day and to open the abscess manually if it closes and express any purulence until it heals.

image

FIGURE 17-10 Paronychia.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 17-11 Incision of paronychia.

(Copyright Richard P. Usatine, MD.)

Complications

• Scarring will occur from an abscess rupturing and thinning the skin. A well-placed incision can lessen the scar or its prominence, but a scar will be present nonetheless.
• Reoccurrence is not unusual due to the wound closing too early or an undiagnosed loculation or due to underlying deeper infection (i.e., osteomyelitis).
• Septicemia, or an advancing deep infection, may occur in association with an abscess (e.g., necrotizing fasciitis).
• Bleeding may occur from damage to blood vessels during the course of incision and drainage or as a result of infection eroding into adjacent vessels.
• Damage to other adjacent structures may also occur as a result of infection eroding into adjacent structures or causing inflammation of nearby structures.

Treating Specific Lesions

• MRSA involvement has increased in recent years, but as mentioned above, evidence does not support the use of antibiotics in addition to I&D in uncomplicated abscesses.
• Because facial abscesses are in a cosmetically sensitive area for scarring, the clinician may initially manage them cautiously with needle aspiration and antibiotics and close follow-up.
• Perirectal abscesses occur in proximity to the anal sphincter and care should be taken to avoid cutting across the sphincter. As with facial abscesses they may be initially managed cautiously with needle aspiration and antibiotics and close follow-up, but have a higher risk of deeper infection and fistula tracking especially with inflammatory bowel disease. Perirectal abscesses more commonly involve anaerobic and gram-negative bacteria.

Special Populations

Immune-compromised patients may be particularly susceptible to localized or systemic infections that present as abscesses or skin infections. Evaluation should take into account the patient’s history, current symptoms, and physical findings. Laboratory testing, imaging studies, and systemic antibiotics may be needed and should be determined based on the overall clinical picture.9 In contrast to routine superficial abscesses, in which culture of the abscess fluid or cavity is not usually required, cultures may be helpful in these patients to guide antibiotic therapy of atypical organisms that may be present.

Coding and Billing Pearls

The CPT codes for I&D are shown in Box 17-1. Note that some specific locations have their own CPT codes. Those specific codes should be used rather than the generic ones since they often reimburse more. These areas include such cutaneous sites as the vulva, eyelid, and pinna. See Table 38-8 in Chapter 38, Surviving Financially, for a full listing of these sites and their reimbursement.

Box 17-1 I&D CPT Codes

10060 Incision and drainage of abscess (cutaneous, subcutaneous abscess, cyst, or paronychia)—simple
10061 Incision and drainage of abscess—multiple or complex (with wound packing)

Conclusion

Patients will present with abscesses as a result of routine situations and sometimes will develop abscesses or wound infections subsequent to procedures performed by the provider. It is important for clinicians treating skin disorders to stock the appropriate items and have the appropriate skills to be able to treat skin abscesses and infections; otherwise, they will have to refer patients in these situations to another provider or facility. Having the skills and equipment to manage these patients adds to the breadth of a provider’s practice.

References

1. Lee MC, Rios AM, Aten MF, et al. Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2004;23(2):123-127.

2. Rajendran PM, Young D, Maurer T, et al. Randomized, double-blind, placebo-controlled trial of cephalexin for treatment of uncomplicated skin abscesses in a population at risk for community-acquired methicillin-resistant Staphylococcus aureus infection. Antimicrob Agents Chemother. 2007;51(11):4044-4048.

3. Loeb M, Main C, Walker-Dilks C, et al. Antimicrobial drugs for treating methicillin-resistant Staphylococcus aureus colonization. Cochrane Database Syst Rev. 2003(4):CD00340.

4. Wendt C, Schinke S, Wurtemberger M, et al. Value of whole-body washing with chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus: a randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol. 2007;28(9):1036-1043.

5. Ho YH, Tan M, Chui CH, et al. Randomized controlled trial of primary fistulotomy with drainage alone for perianal abscesses. Dis Colon Rectum. 1997;40(12):1435-1438.

6. Puymirat E. A Lemierre syndrome variant caused by Staphylococcus aureus. Am J Emerg Med. 2008;26(3):380.e5-380.e7.

7. Korownyk C, Allan GM. Evidence-based approach to abscess management. Can Fam Physician. 2007;53(10):1680-1684.

8. Fitch MT, Manthey DE, McGinnis HD, et al. Videos in clinical medicine. Abscess incision and drainage. N Engl J Med. 2007;357(19):e20.

9. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-1406.

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