The Cheese - Incision & Drainage

Welcome to this week's edition of The Cheese where we will discuss an ED classic, the incision and drainage. Get your scalpels ready as we dive into this cheesy topic!!

INCISION & DRAINAGE

You’re on green team and your patient in bed 8 arrives with a fluctuant back mass. It started as a small pimple, but now it’s a full blown abscess and it’s up to you to pop it. So what’s the deal, can I just suck the pus out, do they need antibiotics, and what about packing? Deep breath, we’re here to discuss all you need to know about this common ED procedure. 

ULTRASOUND

So we think it’s an abscess, but remember, always consider the probe. Using ultrasound has been shown to significantly decrease rates of treatment failure for I&Ds.1 Use it to plan your approach or check for residual purulence after drainage. In cases where you’re unsure if there’s an abscess underlying that nasty cellulitis or wound, definitely grab the probe. Ultrasound has been shown to significantly and appropriately change management in cases where the diagnosis is unclear.2

DIFFERENTIAL

Most abscesses aren't subtle, but there’s always a differential to consider. Particularly in our IVDU population, pseudoaneurysms are a dangerous mimic of an abscess, look for these in the groin and vascular areas. If you’re concerned about necrotizing fasciitis, grab the US to look for ‘STAFF’: Subcutaneous Thickening, Air, and Fascial Fluid. Consider septic bursitis near a joint, vasculitis, or even malignancy. A rare but interesting mimic of a back mass, caught by our own Dr. Dorritie, was an untreated case of spina bifida! If the mass is in a vascular area or there's a question of deeper involvement, consider a CT or specialist input, especially for sensitive areas such as the perineum or neck. 

ANESTHESIA

Once you’ve decided to drain, getting some good anesthesia is key for a successful procedure, so be generous with your lidocaine. Some clinicians inject only where they plan to incise, but I’ve had the best success with this plus a field/ring block, where lidocaine is circumferentially injected around the entire abscess. Another option, particularly helpful in pediatrics, is topical anesthetic; though a small RCT showed no clinically significant difference in pain scores when comparing topical to injectable lidocaine for I&Ds, topicals are still much more manageable for the kiddos.25 Consider nerve blocks, NSAIDs, opioids and even some procedural sedation to get the job done. 

ASPIRATION

The primary goal of abscess management is to get the pus out, and the best way to do this is by making a cut. It’s understandable that neither you nor the patient want to make a big incision, but unfortunately, aspiration failure rates are incredibly high. One study revealed a 75% failure rate of aspiration attempted drainages, with up to 60% of these giving little to no fluid on aspiration.3 With viscous material and loculations, you just can’t get it all out with a needle, and whatever you don’t get out, can’t drain on its own later. Other than for your standard peritonsillar abscess, needling won’t typically cut it. 

IRRIGATION

Once draining, around half of ED providers report that they irrigate the abscess cavity.20 Though literature is sparse here, irrigating doesn’t seem to decrease the need for reintervention after I&D.4 Some studies have compared regular cavity irrigations with sterile solutions and even povidone-iodine solutions, neither of which have been shown to improve outcomes.5,6  So once draining, copious irrigation or special solutions are likely unnecessary, and standard showers at home should suffice. 

PACKING

While irrigating is simple and generally met with little resistance from patients, packing is another story. The patient that just got sweet relief from their popped abscess, is now screaming as I refill the cavity yet again! I was taught to pack a ¼ or ½  inch iodoform gauze into the cavity to be removed after 2 days. For adults with packing there is no significant decrease in the need for repeat interventions, and it seems to just worsen pain for patients.7,12 Similarly, the same lack of benefit holds true for our pediatric patients.10,11 Other studies by our surgical colleagues again show no benefit for perianal abscesses.8,9 Though evidence indicates that packing is not entirely necessary, this practice hasn’t been widely adopted, with one survey revealing that 90% of ED docs still utilize packing.20 Note that some of our consultants may recommend or utilize packing for certain conditions, in which case we would defer to their recommendation. 

 LOOP DRAINAGE

One alternative to traditional I&D is the loop drainage technique. This technique was presented in the early 2000s in the pediatric OR with greatest success and follow up studies.13, 15 It is performed by making an incision at one edge of the abscess, threading a penrose, vessel loop, or sterile band through to the contralateral edge, and then loosely tying it over the skin. Given many EDs don’t readily stock these loops, in true ED MacGyver fashion, one pilot study shows success with cutting the rolled cuff off the bottom of a sterile glove and using this as the loop.14 In the pediatric ED this technique has been shown to be non-inferior and potentially even have decreased failure rates compared to standard I&D.16,17 In the adult ED population this has been highly successful and may even have lower complication rates.18,19  Patients should shower and move the band daily to promote drainage and prevent adhesion of the loop, and once drainage has stopped, one snips the loop and slides it on out.

For more info on the loop drainage method, review this EMRAP video: https://www.emrap.org/episode/loopdrainagefor/loopdrainagefor

ANTIBIOTICS

Historically there was limited evidence to indicate that antibiotics after I&D truly improved outcomes and many major organizations still recommend use in only select cases, such as for overlying cellulitis, immunocompromise, systemic illness, etc.21 However, most organisms identified on wound culture today are MRSA, and two relatively recent meta-analyses have revealed that the use of antibiotics with MRSA coverage after I&D results in decreased rates of  failure, development of new lesions, recurrence, and hospitalization.22-24 There was no benefit to non-MRSA coverage using cephalosporins.23 Though all of these studies utilize clindamycin and bactrim, both bactrim and doxycycline are recommended as first line options for cellulitis with an abscess per our ID guidelines. Considerations should be made on an individual basis and with any indicated specialist guidance, given increasing rates of antibiotic resistance at a population level and the risk of antibiotic-induced side effects.

CONCLUSION

There you have it, a run down of I&Ds. Get a probe and check out that pocket. Ditch the needle and dive right in with a cut. No need to go crazy with the irrigation or packing, and consider grabbing a sterile glove for the loop drainage technique instead. Finally, consider MRSA coverage after a discussion about risks and benefits with your patient and team. Now grab your scalpel and get out there!

For anyone interested in the literature, check out this annotated bibliography. 

Great job out there everyone!

The Cheese Team

Dr. Leser, Samson, Mac, and Nanditha (we'll miss you Taylor!)

CITATIONS

  1. Gaspari RJ, Sanseverino A, Gleeson T. Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial. Annals of emergency medicine. 2019;73(1):1-7. doi:10.1016/j.annemergmed.2018.05.014

  2. Mower WR, Crisp JG, Krishnadasan A, et al. Effect of Initial Bedside Ultrasonography on Emergency Department Skin and Soft Tissue Infection Management. Annals of emergency medicine. 2019;74(3):372-380. doi:10.1016/j.annemergmed.2019.02.002

  3. Gaspari RJ, Resop D, Mendoza M, Kang T, Blehar D. A Randomized Controlled Trial of Incision and Drainage Versus Ultrasonographically Guided Needle Aspiration for Skin Abscesses and the Effect of Methicillin-Resistant Staphylococcus aureus. Annals of emergency medicine. 2011;57(5):483-491.e1. doi:10.1016/j.annemergmed.2010.11.021

  4. Chinnock, B., & Hendey, G. W. (2016). Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success. Annals of Emergency Medicine, 67(3), 379–383. https://doi.org/10.1016/j.annemergmed.2015.08.007

  5. Oehme F, Rühle A, Börnert K, Hempel S, Link BC, Babst R, Metzger J, Beeres FJ. Simple Wound Irrigation in the Postoperative Treatment for Surgically Drained Spontaneous Soft Tissue Abscesses: A Prospective, Randomized Controlled Trial. World J Surg. 2020 Dec;44(12):4041-4051. doi: 10.1007/s00268-020-05738-1. Epub 2020 Aug 18. PMID: 32812137.

  6. Olson, A. S., Rosenblatt, L., Salerno, N., Odette, J., Ren, R., Emanuel, T., Michalek, J., Liu, Q., Du, L., Jahangir, K., & Schmitz, G. R. (2019). Pilot Study to Evaluate the Adjunct Use of a Povidone-Iodine Topical Antiseptic in Patients with Soft Tissue Abscesses. The Journal of Emergency Medicine, 56(4), 405–412. https://doi.org/10.1016/j.jemermed.2018.12.026  

  7.  O'Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009 May;16(5):470-3. doi: 10.1111/j.1553-2712.2009.00409.x. Epub 2009 Apr 10. PMID: 19388915.

  8. Newton K, Dumville J, Briggs M, Law J, Martin J, Pearce L, Kirwan C, Pinkney T, Needham A, Jackson R, Winn S, McCulloch H, Hill J; PPAC2 Collaborators. Postoperative Packing of Perianal Abscess Cavities (PPAC2): randomized clinical trial. Br J Surg. 2022 Sep 9;109(10):951-957. doi: 10.1093/bjs/znac225. PMID: 35929816; PMCID: PMC10364677.

  9. Crook, D., & Padfield, O. (2025). A systematic review and meta-analysis of the use of packing in the management of perianal abscesses. Annals of the Royal College of Surgeons of England, 107(1), 29–34. https://doi.org/10.1308/rcsann.2023.0108

  10. Kessler, D. O. , Krantz, A. & Mojica, M. (2012). Randomized Trial Comparing Wound Packing to No Wound Packing Following Incision and Drainage of Superficial Skin Abscesses in the Pediatric Emergency Department. Pediatric Emergency Care, 28 (6), 514-517. doi: 10.1097/PEC.0b013e3182587b20.

  11. Leinwand M, Downing M, Slater D, Beck M, Burton K, Moyer D. Incision and drainage of subcutaneous abscesses without the use of packing. J Pediatr Surg. 2013 Sep;48(9):1962-5. doi: 10.1016/j.jpedsurg.2013.01.027. PMID: 24074675.

  12. Mohamedahmed AYY, Zaman S, Stonelake S, Ahmad AN, Datta U, Hajibandeh S, Hajibandeh S. Incision and drainage of cutaneous abscess with or without cavity packing: a systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials. Langenbecks Arch Surg. 2021 Jun;406(4):981-991. doi: 10.1007/s00423-020-01941-9. Epub 2020 Aug 1. PMID: 32740696. 

  13. Ladd, A. P., Levy, M. S., & Quilty, J. (2010). Minimally invasive technique in treatment of complex, subcutaneous abscesses in children. Journal of Pediatric Surgery, 45(7), 1562–1566. https://doi.org/10.1016/j.jpedsurg.2010.03.025

  14. Thompson, D. O. (2014). Loop Drainage of Cutaneous Abscesses Using a Modified Sterile Glove: A Promising Technique. The Journal of Emergency Medicine, 47(2), 188–191. https://doi.org/10.1016/j.jemermed.2014.04.035

  15. Aprahamian, C. J., Nashad, H., DiSomma, N., Elger, B., Esparaz, J., McMorrow, T., Shadid, A., Kao, A., Holterman, M. J., Kanard, R. C., & Pearl, R. H. (2017). Treatment of Subcutaneous Abscesses in Children with Incision and Loop Drainage: A Simplified Method of Care. Journal of Pediatric Surgery, 52(9), 1438–1441. https://doi.org/10.1016/j.jpedsurg.2016.12.018

  16. Rencher, L., Whitaker, W., Schechter-Perkins, E., & Wilkinson, M. (2021). Comparison of Minimally Invasive Loop Drainage and Standard Incision and Drainage of Cutaneous Abscesses in Children Presenting to a Pediatric Emergency Department: A Prospective, Randomized, Noninferiority Trial. Pediatric Emergency Care, 37(10), e615–e620. https://doi.org/10.1097/PEC.0000000000001732

  17. Ladde JG, Baker S, Rodgers CN, Papa L. The loop technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED. The American journal of emergency medicine. 2015;33(2):271-276. doi:10.1016/j.ajem.2014.10.014

  18. Gaszynski, R., Punch, G., & Verschuer, K. (2018). Loop and drain technique for subcutaneous abscess: a safe minimally invasive procedure in an adult population. ANZ Journal of Surgery, 88(1–2), 87–90. https://doi.org/10.1111/ans.13709

  19. Schechter‐Perkins EM, Dwyer KH, Amin A, et al. Loop Drainage Is Noninferior to Traditional Incision and Drainage of Cutaneous Abscesses in the Emergency Department. Academic emergency medicine. 2020;27(11):1150-1157. doi:10.1111/acem.13981

  20. Schmitz, G., Goodwin, T., Singer, A., Kessler, C., Bruner, D., Larrabee, H., May, L., Luber, S., Williams, J., & Bhat, R. (2013). The Treatment of Cutaneous Abscesses: Comparison of Emergency Medicine Providers’ Practice Patterns. The Western Journal of Emergency Medicine, 14(1), 23–28. https://doi.org/10.5811/westjem.2011.9.6856

  21. Schmitz, G. R. (2011). How Do You Treat an Abscess in the Era of Increased Community-associated Methicillin-resistant Staphylococcus Aureus (MRSA)? The Journal of Emergency Medicine, 41(3), 276–281. https://doi.org/10.1016/j.jemermed.2011.01.027

  22. Gottlieb M, DeMott JM, Hallock M, Peksa GD. Systemic Antibiotics for the Treatment of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-Analysis. Annals of emergency medicine. 2019;73(1):8-16. doi:10.1016/j.annemergmed.2018.02.011

  23. Wang W, Chen W, Liu Y, et al. Antibiotics for uncomplicated skin abscesses: systematic review and network meta-analysis. BMJ open. 2018;8(2):e020991-e020991. doi:10.1136/bmjopen-2017-020991

  24. Menegas, S., Moayedi, S., & Torres, M. (2021). Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians. The Journal of Emergency Medicine, 60(3), 310–320. https://doi.org/10.1016/j.jemermed.2020.10.043

  25. Bourne CL, Brewer KL, House J. Injectable Lidocaine Provides Similar Analgesia Compared to Transdermal Lidocaine/Tetracaine Patch for the Incision and Drainage of Skin Abscesses: A Randomized, Controlled Trial. The Journal of emergency medicine. 2014;47(3):367-371. doi:10.1016/j.jemermed.2013.11.126