An abscess is a collection of
pus
Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection ...
that has built up within the
tissue of the body.
[ Signs and symptoms of abscesses include redness, pain, warmth, and swelling.][ The swelling may feel fluid-filled when pressed.][ The area of redness often extends beyond the swelling.] Carbuncle
A carbuncle is a cluster of boils caused by bacterial infection, most commonly with ''Staphylococcus aureus'' or ''Streptococcus pyogenes''. The presence of a carbuncle is a sign that the immune system is active and fighting the infection. The ...
s and boil
A boil, also called a furuncle, is a deep folliculitis, which is an infection of the hair follicle. It is most commonly caused by infection by the bacterium ''Staphylococcus aureus'', resulting in a painful swollen area on the skin caused by an ...
s are types of abscess that often involve hair follicle
The hair follicle is an organ found in mammalian skin. It resides in the dermal layer of the skin and is made up of 20 different cell types, each with distinct functions. The hair follicle regulates hair growth via a complex interaction between h ...
s, with carbuncles being larger.
They are usually caused by a bacterial infection
Pathogenic bacteria are bacteria that can cause disease. This article focuses on the bacteria that are pathogenic to humans. Most species of bacteria are harmless and are often beneficial but others can cause infectious diseases. The number of ...
. Often many different types of bacteria are involved in a single infection.[ In many areas of the world, the most common bacteria present is '']methicillin-resistant Staphylococcus aureus
Methicillin-resistant ''Staphylococcus aureus'' (MRSA) is a group of Gram-positive bacteria that are genetically distinct from other strains of ''Staphylococcus aureus''. MRSA is responsible for several difficult-to-treat infections in humans. ...
''.[ Rarely, ]parasites
Parasitism is a Symbiosis, close relationship between species, where one organism, the parasite, lives on or inside another organism, the Host (biology), host, causing it some harm, and is Adaptation, adapted structurally to this way of lif ...
can cause abscesses; this is more common in the developing world
A developing country is a sovereign state with a lesser developed industrial base and a lower Human Development Index (HDI) relative to other countries. However, this definition is not universally agreed upon. There is also no clear agreem ...
.[ Diagnosis of a skin abscess is usually made based on what it looks like and is confirmed by cutting it open.][ ]Ultrasound
Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
imaging may be useful in cases in which the diagnosis is not clear.[ In abscesses around the ]anus
The anus (Latin, 'ring' or 'circle') is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, the residual semi-solid waste that remains after food digestion, which, d ...
, computer tomography (CT) may be important to look for deeper infection.
Standard treatment for most skin or soft tissue abscesses is cutting it open and drainage. There appears to be some benefit from also using antibiotic
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
s. A small amount of evidence supports not packing the cavity that remains with gauze
Gauze is a thin, translucent fabric with a loose open weave. In technical terms "gauze" is a weave structure in which the weft yarns are arranged in pairs and are crossed before and after each warp yarn keeping the weft firmly in place. ...
after drainage. Closing this cavity right after draining it rather than leaving it open may speed healing without increasing the risk of the abscess returning. Sucking out the pus with a needle is often not sufficient.[
Skin abscesses are common and have become more common in recent years.][ Risk factors include ]intravenous drug use
Drug injection is a method of introducing a drug into the bloodstream via a hollow hypodermic needle, which is pierced through the skin into the body (usually intravenously, but also at an intramuscular or subcutaneous location). Intravenou ...
, with rates reported as high as 65% among users. In 2005, 3.2 million people went to American emergency departments for abscesses. In Australia, around 13,000 people were hospitalized in 2008 with the condition.
Signs and symptoms
Abscesses may occur in any kind of tissue but most frequently within the skin surface (where they may be superficial pustules known as boil
A boil, also called a furuncle, is a deep folliculitis, which is an infection of the hair follicle. It is most commonly caused by infection by the bacterium ''Staphylococcus aureus'', resulting in a painful swollen area on the skin caused by an ...
s or deep skin abscesses), in the lungs
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of th ...
, brain
A brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as vision. It is the most complex organ in a v ...
, teeth
A tooth ( : teeth) is a hard, calcified structure found in the jaws (or mouths) of many vertebrates and used to break down food. Some animals, particularly carnivores and omnivores, also use teeth to help with capturing or wounding prey, tear ...
, kidneys, and tonsils. Major complications may include spreading of the abscess material to adjacent or remote tissues, and extensive regional tissue death (gangrene
Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the ga ...
).
The main symptoms and signs of a skin abscess are redness, heat, swelling, pain, and loss of function. There may also be high temperature (fever) and chills. If superficial, abscesses may be fluctuant when palpated
Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a health care practitioner, it is the process of feeling an object in or on the body to determine ...
; this wave-like motion is caused by movement of the pus inside the abscess.
An internal abscess is more difficult to identify, but signs include pain in the affected area, a high temperature, and generally feeling unwell.
Internal abscesses rarely heal themselves, so prompt medical attention is indicated if such an abscess is suspected. An abscess can potentially be fatal depending on where it is located.
Causes
Risk factors for abscess formation include intravenous drug use
Drug injection is a method of introducing a drug into the bloodstream via a hollow hypodermic needle, which is pierced through the skin into the body (usually intravenously, but also at an intramuscular or subcutaneous location). Intravenou ...
. Another possible risk factor is a prior history of disc herniation or other spinal abnormality, though this has not been proven.
Abscesses are caused by bacterial infection
Pathogenic bacteria are bacteria that can cause disease. This article focuses on the bacteria that are pathogenic to humans. Most species of bacteria are harmless and are often beneficial but others can cause infectious diseases. The number of ...
, parasites, or foreign substances.
Bacterial infection is the most common cause, particularly Staphylococcus aureus
''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often positive ...
. The more invasive ''methicillin-resistant Staphylococcus aureus
Methicillin-resistant ''Staphylococcus aureus'' (MRSA) is a group of Gram-positive bacteria that are genetically distinct from other strains of ''Staphylococcus aureus''. MRSA is responsible for several difficult-to-treat infections in humans. ...
'' (MRSA) may also be a source of infection, though is much rarer. Among spinal subdural abscesses, methicillin-sensitive ''Staphylococcus aureus'' is the most common organism involved.[
Rarely ]parasites
Parasitism is a Symbiosis, close relationship between species, where one organism, the parasite, lives on or inside another organism, the Host (biology), host, causing it some harm, and is Adaptation, adapted structurally to this way of lif ...
can cause abscesses and this is more common in the developing world.[ Specific parasites known to do this include ]dracunculiasis
Dracunculiasis, also called Guinea-worm disease, is a parasitic infection by the Guinea worm, ''Dracunculus medinensis''. A person becomes infected by drinking water containing water fleas infected with guinea worm larvae. The worms penetrate th ...
and myiasis
Myiasis is the parasitic infestation of the body of a live animal by fly larvae (maggots) which grow inside the host while feeding on its tissue. Although flies are most commonly attracted to open wounds and urine- or feces-soaked fur, some spec ...
.[
]
Perianal abscess
Surgery of the anal fistula
Anal fistula is a chronic abnormal communication between the epithelialised surface of the anal canal and usually the perianal skin. An anal fistula can be described as a narrow tunnel with its internal opening in the anal canal and its externa ...
to drain an abscess treats the fistula and reduces likelihood of its recurrence and the need for repeated surgery. There is no evidence that fecal incontinence
Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred ...
is a consequence of this surgery for abscess drainage.
Perianal abscess
Anorectal abscess (also known as an anal/rectal abscess, or perianal/perirectal abscess) is an abscess adjacent to the anus. Most cases of perianal abscesses are sporadic, though there are certain situations which elevate the risk for developin ...
es can be seen in people with, for example, inflammatory bowel disease
Inflammatory bowel disease (IBD) is a group of inflammation, inflammatory conditions of the colon (anatomy), colon and small intestine, Crohn's disease and ulcerative colitis being the principal types. Crohn's disease affects the small intestine a ...
(such as Crohn's disease
Crohn's disease is a type of inflammatory bowel disease (IBD) that may affect any segment of the gastrointestinal tract. Symptoms often include abdominal pain, diarrhea (which may be bloody if inflammation is severe), fever, abdominal distension ...
) or diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
. Often the abscess will start as an internal wound caused by ulceration, hard stool, or penetrative objects with insufficient lubrication. This wound typically becomes infected as a result of the normal presence of feces in the rectal area, and then develops into an abscess. This often presents itself as a lump of tissue near the anus
The anus (Latin, 'ring' or 'circle') is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, the residual semi-solid waste that remains after food digestion, which, d ...
which grows larger and more painful with time. Like other abscesses, perianal abscesses may require prompt medical treatment, such as an incision and debridement
Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy.
In p ...
or lancing.
Incisional abscess
An ''incisional abscess'' is one that develops as a complication secondary to a surgical incision
In surgery, a surgical incision is a cut made through the skin and soft tissue to facilitate an Surgery, operation or medical procedure, procedure. Often, multiple incisions are possible for an operation. In general, a surgical incision is made as ...
. It presents as redness and warmth at the margins of the incision with purulent drainage from it. If the diagnosis is uncertain, the wound should be aspirated with a needle, with aspiration of pus confirming the diagnosis and availing for Gram stain
In microbiology and bacteriology, Gram stain (Gram staining or Gram's method), is a method of staining used to classify bacterial species into two large groups: gram-positive bacteria and gram-negative bacteria. The name comes from the Danish ...
and bacterial culture
A microbiological culture, or microbial culture, is a method of multiplying microbial organisms by letting them reproduce in predetermined culture medium under controlled laboratory conditions. Microbial cultures are foundational and basic diagn ...
.
Pathophysiology
An abscess is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body.
Organisms or foreign materials destroy the local cells, which in the release of cytokine
Cytokines are a broad and loose category of small proteins (~5–25 kDa) important in cell signaling. Cytokines are peptides and cannot cross the lipid bilayer of cells to enter the cytoplasm. Cytokines have been shown to be involved in autocrin ...
s. The cytokines trigger an inflammatory response
Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molecu ...
, which draws large numbers of white blood cell
White blood cells, also called leukocytes or leucocytes, are the cell (biology), cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and de ...
s to the area and increases the regional blood flow.
The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object.
File:Blausen 0007 Abscess.png, A diagram of an abscess
file:Pyemic abscesses of kidney.jpg, Pyemic abscesses of a kidney
The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blood ...
Diagnosis
An abscess is a localized collection of pus (purulent inflammatory tissue) caused by suppuration buried in a tissue, an organ, or a confined space, lined by the pyogenic membrane. Ultrasound
Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
imaging can help in a diagnosis.
Classification
Abscesses may be classified as either ''skin abscesses'' or ''internal abscesses''. Skin abscesses are common; internal abscesses tend to be harder to diagnose, and more serious. Skin abscesses are also called cutaneous or subcutaneous abscesses.
IV drug use
For those with a history of intravenous drug use, an X-ray
An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...
is recommended before treatment to verify that no needle fragments are present.[ If there is also a fever present in this population, ]infectious endocarditis
Infective endocarditis is an infection of the inner surface of the heart, usually the valves. Signs and symptoms may include fever, small areas of bleeding into the skin, heart murmur, feeling tired, and low red blood cell count. Complications ...
should be considered.[
]
Differential
Abscesses should be differentiated from empyema
An empyema () is a collection or gathering of pus within a naturally existing anatomical cavity. For example, pleural empyema is empyema of the pleural cavity. It must be differentiated from an abscess, which is a collection of pus in a newly fo ...
s, which are accumulations of pus in a preexisting, rather than a newly formed, anatomical cavity.
Other conditions that can cause similar symptoms include: cellulitis
Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of t ...
, a sebaceous cyst
A sebaceous cyst is a term commonly used to refer to either:
* Epidermoid cysts (also termed epidermal cysts, infundibular cyst)
* Pilar cysts (also termed trichelemmal cysts, isthmus-catagen cysts)
Both of the above types of cysts contain kera ...
, and necrotising fasciitis
Necrotizing fasciitis (NF), also known as flesh-eating disease, is a bacterial infection that results in the death of parts of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms usually include red or p ...
.[ Cellulitis typically also has an erythematous reaction, but does not confer any purulent drainage.]
Treatment
The standard treatment for an uncomplicated skin or soft tissue abscess is the act of opening and draining. There does not appear to be any benefit from also using antibiotic
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
s in most cases.[ A small amount of evidence did not find a benefit from packing the abscess with gauze.][
]
Incision and drainage
The abscess should be inspected to identify if foreign objects are a cause, which may require their removal. If foreign objects are not the cause, incising and draining the abscess is standard treatment.
In critical areas where surgery presents a high risk, it may be delayed or used as a last resort. The drainage of a lung abscess may be performed by positioning the affected individual in a way that enables the contents to be discharged via the respiratory tract
The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa.
Air is breathed in through the nose to th ...
. Warm compresses and elevation of the limb may be beneficial for a skin abscess.
Antibiotics
Most people who have an uncomplicated skin abscess should not use antibiotics. Antibiotics in addition to standard incision and drainage is recommended in persons with severe abscesses, many sites of infection, rapid disease progression, the presence of cellulitis
Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of t ...
, symptoms indicating bacterial illness throughout the body, or a health condition causing immunosuppression
Immunosuppression is a reduction of the activation or efficacy of the immune system. Some portions of the immune system itself have immunosuppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse react ...
.[ People who are very young or very old may also need antibiotics.][ If the abscess does not heal only with incision and drainage, or if the abscess is in a place that is difficult to drain such as the face, hands, or genitals, then antibiotics may be indicated.][
In those cases of abscess which do require antibiotic treatment, '']Staphylococcus aureus
''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often positive ...
'' bacteria is a common cause and an anti-staphylococcus antibiotic such as flucloxacillin
Flucloxacillin, also known as floxacillin, is an antibiotic used to treat skin infections, external ear infections, infections of leg ulcers, diabetic foot infections, and infection of bone. It may be used together with other medications to t ...
or dicloxacillin
Dicloxacillin is a narrow-spectrum β-lactam antibiotic of the penicillin class. It is used to treat infections caused by susceptible (non-resistant) Gram-positive bacteria.Product Information: DICLOXACILLIN SODIUM-dicloxacillin sodium capsule. T ...
is used. The Infectious Diseases Society of America
The Infectious Diseases Society of America (IDSA) is a medical association representing physicians, scientists and other health care professionals who specialize in infectious diseases. It was founded in 1963 and is based in Arlington, Virginia. ...
advises that the draining of an abscess is not enough to address community-acquired methicillin-resistant ''Staphylococcus aureus'' (MRSA), and in those cases, traditional antibiotics may be ineffective.[ Alternative antibiotics effective against community-acquired MRSA often include ]clindamycin
Clindamycin is an antibiotic medication used for the treatment of a number of bacterial infections, including osteomyelitis (bone) or joint infections, pelvic inflammatory disease, strep throat, pneumonia, acute otitis media (middle ear infec ...
, doxycycline
Doxycycline is a broad-spectrum tetracycline class antibiotic used in the treatment of infections caused by bacteria and certain parasites. It is used to treat bacterial pneumonia, acne, chlamydia infections, Lyme disease, cholera, typhus, an ...
, minocycline
Minocycline, sold under the brand name Minocin among others, is a tetracycline antibiotic medication used to treat a number of bacterial infections such as pneumonia. It is generally less preferred than the tetracycline doxycycline. It is also ...
, and trimethoprim-sulfamethoxazole
Trimethoprim/sulfamethoxazole, sold under the brand name Bactrim among others, is a fixed-dose combination antibiotic medication used to treat a variety of bacterial infections. It consists of one part trimethoprim to five parts sulfamethoxazo ...
.[ The ]American College of Emergency Physicians
The American College of Emergency Physicians (ACEP) is a professional organization of emergency medicine physicians in the United States.
The organization was founded August 16, 1968, by eight physicians in Lansing, Michigan. ACEP established ...
advises that typical cases of abscess from MRSA get no benefit from having antibiotic treatment in addition to the standard treatment. If the condition is thought to be cellulitis
Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of t ...
rather than an abscess, consideration should be given to the possibility of the strep species as a cause, that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin. This would be in the case of people that are able to tolerate penicillin. Antibiotic
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
therapy alone without surgical drainage of the abscess is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low pH levels.
Culturing the wound is not needed if standard follow-up care can be provided after the incision and drainage. Performing a wound culture is unnecessary because it rarely gives information which can be used to guide treatment.
Packing
In North America, after drainage, an abscess cavity is usually packed, often with special iodoform-treated cloth. This is done to absorb and neutralize any remaining exudate as well as to promote draining and prevent premature closure. Prolonged draining is thought to promote healing. The hypothesis is that though the heart's pumping action can deliver immune and regenerative cells to the edge of an injury, an abscess is by definition a void in which no blood vessels are present. Packing is thought to provide a wicking action that continuously draws beneficial factors and cells from the body into the void that must be healed. Discharge is then absorbed by cutaneous bandages and further wicking promoted by changing these bandages regularly. However, evidence from emergency medicine literature reports that packing wounds after draining, especially smaller wounds, causes pain to the person and does not decrease the rate of recurrence, nor bring faster healing, or fewer physician visits.
Loop drainage
More recently, several North American hospitals have opted for less-invasive loop drainage over standard drainage and wound packing. In one study of 143 pediatric outcomes, a failure rate of 1.4% was reported in the loop group versus 10.5% in the packing group (P<.030), while a separate study reported a 5.5% failure rate among the loop group.
Primary closure
Closing an abscess immediately after draining it appears to speed healing without increasing the risk of recurrence.[ This may not apply to anorectal abscesses as while they may heal faster, there may be a higher rate of recurrence than those left open.]
Prognosis
Even without treatment, skin abscesses rarely result in death, as they will naturally break through the skin.[ Other types of abscess are more dangerous. Brain abscesses may be fatal if untreated. When treated, the mortality rate reduces to 5–10%, but is higher if the abscess ruptures.
]
Epidemiology
Skin abscesses are common and have become more common in recent years.[ Risk factors include ]intravenous drug use
Drug injection is a method of introducing a drug into the bloodstream via a hollow hypodermic needle, which is pierced through the skin into the body (usually intravenously, but also at an intramuscular or subcutaneous location). Intravenou ...
, with rates reported as high as 65% among users.[ In 2005, in the United States 3.2 million people went to the emergency department for an abscess.][ In Australia around 13,000 people were hospitalized in 2008 for the disease.][
]
Society and culture
The Latin
Latin (, or , ) is a classical language belonging to the Italic branch of the Indo-European languages. Latin was originally a dialect spoken in the lower Tiber area (then known as Latium) around present-day Rome, but through the power of the ...
medical aphorism
An aphorism (from Greek ἀφορισμός: ''aphorismos'', denoting 'delimitation', 'distinction', and 'definition') is a concise, terse, laconic, or memorable expression of a general truth or principle. Aphorisms are often handed down by tra ...
"''''" expresses "where there is pus, there evacuate it" and is classical advice in the culture of Western medicine.
Needle exchange programmes
A needle and syringe programme (NSP), also known as needle exchange program (NEP), is a social service that allows injecting drug users (IDUs) to obtain clean and unused hypodermic needles and associated paraphernalia at little or no cost. It ...
often administer or provide referrals for abscess treatment to injection drug users as part of a harm reduction
Harm reduction, or harm minimization, refers to a range of public health policies designed to lessen the negative social and/or physical consequences associated with various human behaviors, both legal and illegal. Harm reduction is used to de ...
public health strategy.
Etymology
An abscess is so called "abscess" because there is an ''abscessus'' (a going away or departure) of portions of the animal tissue from each other to make room for the suppurated matter lodged between them.
The word carbuncle is believed to have originated from the Latin: ''carbunculus'', originally a small coal; diminutive of ''carbon-'', ''carbo'': charcoal or ember, but also a carbuncle stone, "precious stones of a red or fiery colour", usually garnet
Garnets () are a group of silicate minerals that have been used since the Bronze Age as gemstones and abrasives.
All species of garnets possess similar physical properties and crystal forms, but differ in chemical composition. The different s ...
s.
Other types
The following types of abscess are listed in the medical dictionary:
References
External links
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{{Authority control
General surgery
Cutaneous lesion
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