| • | (really a hair follicle infection) |
| • | = pus-filled nodules in the dermis |
| • | abscess: often arise from traumatic inoculation of bacteria into the skin |
| • | furuncle (boil): the bacteria enter by a hair follicle where they form a deep folliculitis and extend into the surrounding dermis |
| • | carbuncle: same as a furuncle, but worse (deeper, bigger) |
| • | organism = usually S. aureus |
| • | clinical ddx - ruptured cyst (history of a bump for years that just "blew up" recently) |
TREATMENT:
| • | incision and drainage (and culture the pus) |
When to use antibiotics:
| • | three situations: 1 - if there is surrounding cellulitis, 2 - if there are multiple boils, 3 - (sometimes) if the patient is immunocompromised |
| • | I have never used antibiotics after incising and draining a boil (except the above situations) |
| • | even if MRSA comes back on culture - the patient gets better without antibiotics |
| • | when I have used antibiotics, I have never had to use anything other than Keflex (except when a patient is penicillin-allergic) - and again, even MRSA responds (by the time I get the culture back that says MRSA, I call the patient and they are already better) |
| • | UPDATE 2009 - I now use doxycycline first-line instead of Keflex because in our community, even MRSA is sensitive to doxycycline |
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recurrent furunculosis:
| • | twice daily intra-nasal application of antibiotic ointment (mupirocin topical 2% bid X 5 days) |
| • | mupirocin intranasal effective vs. S. aureus (10 - 50% MRSA are resistant to mupirocin per Dirk Elston, MD December 2010) |
| • | less resistance to neomycin, Silvadene, retapamulin, or topical gentamicin |
| • | clindamycin 150qd x 1 month to eliminate nasal carriage (or rifampin/minocycline NOT doxycycline, which does not get into nares) |
| • | don't forget benzoyl peroxide (effective against staph with little to no resistance) |
| • | use mupirocin behind the ears and in the belly button when they apply it intranasally (and repeat this each month for five days as prophylaxis) |
| • | use Hibiclens in the shower as a body wash |
| • | don't share towels, do throw away old sponges etc... from the bathroom |
| • | have housemates do all of the above as well (they may be carriers who are less susceptible to infection but keep reinfecting your susceptible patient) |
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