Management of Cutaneous Abscesses by Dermatologists
February 2014 | Volume 13 | Issue 2 | 119 | Copyright © February 2014
Jason Chouake MD,a Aimee Krausz BA,b Brandon L. Adler BA,b Hillel W. Cohen PhD MPH,c
Joshua D. Nosanchuk MD,d,e and Adam Friedman MDb,f
aDepartment of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
bDivision of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
cDepartment of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
dDivision of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
eDepartment of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY
fDepartment of Physiology and Biophysics, Albert Einstein College of Medicine, Bronx, NY
Abstract
IMPORTANCE: There is currently no data detailing the degree to which dermatologists follow CDC/Infectious Diseases Society of America
(IDSA) guidelines in the treatment of abscesses, which recommend that incision and drainage (I+D) as primary therapy for skin and
soft tissue infections (SSTI).
OBJECTIVE: To evaluate the management of skin abscesses by dermatologists.
DESIGN, SETTING, PARTICIPANTS: A national email survey of 780 dermatologists was conducted from May-June 2012. Awareness, experience,
and preparedness of respondents for abscess treatment, as well as the treatment practices in different clinical scenarios were
evaluated. Response rate = 65% (n=510). Eligibility criteria: board certified/eligible dermatologists practicing in US. Main practice affiliation:
solo (20%), group (33%), university health system/academic (32%), multi-specialty (13%), and other (2%). Main practice setting:
urban (49%), suburban (42%), and rural (9%).
MAIN OUTCOME and MEASURES: Practitioner report of: awareness of national guidelines, use of I+D in initial management of uncomplicated
abscess found on face, trunk, and extremity on patients age 6 months, 3, 15, 50, and 80 years, and use of antibiotics in the
initial management.
RESULTS: 99% of respondents were capable of performing I+D in their practice. The IDSA recommends cultures in all patients treated with
antibiotic therapy, and does not recommend antibiotics for the treatment of simple abscess. 18% of respondents reported culturing abscesses
less than 50% of the time, while 91% incorporated antibiotics into initial treatment. Nearly a quarter (24%) of respondents would
choose an initial antibiotic that would not cover Methicillin-resistant Staphylococcus aureus (MRSA). For facial abscesses, as the age of
the patient increased from infant, respondents were more likely to incorporate I+D into their initial treatment. For abscesses on the trunk
and extremities, respondents were less likely to I+D infants and toddlers, compared to adolescents, adults and the elderly.
CONCLUSION: Although most dermatologists were prepared to manage uncomplicated abscesses (98%), this survey identifies gaps in
clinical standards of care established by the CDC/IDSA. Identification of these practice gaps may impact physician practice and dermatology
residency curricula, and may serve to improve abscess management and antibacterial stewardship in the outpatient setting.
J Drugs Dermatol. 2014;13(2):119-124.
INTRODUCTION
Skin and soft tissue infections (SSTIs) are generally uncomplicated
at the time of initial presentation. However, these
infections can worsen quickly when there are delays in
presentation and treatment. When encountering these infections,
physicians must respond quickly with an appropriate
therapeutic plan.1 Physicians must also be aware of trends in
microbial resistance, in order to optimize patient care.2
Staphylococcus aureus is the most frequent cause of skin and
soft tissue infections in the United States.3 With the expanding
prevalence of SSTIs caused by community associated methicillin
resistant Staphylococcus aureus (CA-MRSA), the Centers
for Disease Control and Prevention (CDC) have developed
clinical care guidelines that emphasized the need to (a) consider
MRSA in the differential diagnosis of all skin abscesses,
(b) perform incision and drainage (I+D) of skin abscesses, and
(c) to use culture results and antimicrobial sensitivity to guide
antibiotic treatment.4 The Infectious Diseases Society of America
recommends antibiotic treatment only after incision and
drainage of an abscess when there is (a) severe of extensive
disease, (b) signs and symptoms of systemic disease, (c) associated
comorbidities of immunosuppression, (d) extremes
in age, (e) abscess in an area difficult to drain completely
(face, hand, genitalia), (f) associated septic phlebitis, (g) lack
of response to incision and drainage alone.1 When antibiotic
treatment is indicated for the treatment of acute bacterial skin
and skin structure infections (ABSSSI), the IDSA recommends
empiric coverage of CA- MRSA in the outpatient setting, pending
culture results.1
Kemper et al, in a recent study5 surveyed a random sample
of 385 general pediatricians to evaluate primary care pediatricians’
management of skin abscesses. In this study,
respondents were less likely to I+D a 6-month-old when
