Identification, Treatment and Prevention
Abscesses are something most of us have encountered before and they can be everything from hardly noticeable, to extremely painful. Sympathetic or accessible, affordable medical care can be hard to come by for many of us around the world who use drugs and so some people resort to treating themselves, for reasons of cost, access, stigma or fear. This can lead to some serious complications as the toxicity of an abscess can vary considerably. Here are a few things to remember when it comes to getting to grips with an abscess -and whether you can really treat it yourself. Yes, this is a big article and has had a major update, but it is worth reading the whole thing if you are concerned about abscesses, or at least read the summary!
NOTE: This article was updated on the 1st November 2015 due to a reasonable shift in the way we look at abscesses and our use of antibiotics and wound care has progressed over the last decade.
Abscesses present themselves as raised lumps on the skin and can either be sterile or infected.
Many drug injectors will have an abscess at some stage in their injecting careers but it is by no means a certainty – many can be prevented. Even if you haven’t had an abscess but your partner or flatmate has, read this article because germs travel and can be infectious.
A Sterile or Infected Abscess?
There are two types of abscesses, septic and sterile. Most abscesses are septic, which means that they are the result of an infection.
A Sterile Abscess is caused by injecting either an irritating or insoluble substance into a vein – and if some of the cut in your drugs are insoluble, a sterile abscess is sometimes formed. It is basically a milder form of the same process of an infected abscess, caused not by germs this time but by nonliving irritants such as drugs. If an injected drug is not absorbed, it stays where it was injected and may cause enough irritation to generate a sterile abscess—sterile because there is no infection involved. Sterile abscesses are quite likely to turn into hard, solid lumps as they scar, rather than remaining pockets of pus. It will not usually show signs of heat although there may be a touch of redness and it can feel like a solid nodule under the skin and isn’t likely to be sore. Soreness will depend on the volume of substance under the skin. Don’t try to squeeze or poke it as it will usually go away in its own time and squeezing it could induce an infection.
A Septic or an Infected Abscess can occur anywhere in the body. In the injecting community in which we are referring to here, these can be caused by either using non-sterile injecting equipment or by bacteria from your skin entering under the skin via the injecting process. An infected abscess will soon come up as a swollen lump on or near the injection site. Appearing inflamed and red, it feels hot to the touch and soon becomes very painful. The abscess may come to a ‘head’ or ‘point’ and be filled with pus. Sometimes a deep abscess will eat a small channel (sinus) to the surface and begin leaking pus. It can be tempting to squeeze or burst it now – but DON’T! This will only spread the infection, driving it deeper and wider, and it could head for the bloodstream making you very ill by giving you blood poisoning which can be fatal! Only a germ and the body’s immune response are required.
A good way to decide if yours is infected or sterile -feel for heat (warm is infection) and a lot of pain (infected). If not it should go away on its own.
As the ‘drugs war’ rages on, the ricochet effects continue to reverberate around the drug using community. Abscesses have become our battle scars but it is important to remember that you don’t have to end up with huge circular scars on your body. If you are concerned about your scars early treatment of your abscess will help keep scarring to a minimum. There are camouflage creams available to conceal scars – you can ask for a referral from a doctor to a clinic that will guide you in their use and help with the creams application or google some of the excellent camouflage creams available and vitamin E oils and creams for healing scar tissue.
If you want to know what inside your abscess – here’s a little insight.
What’s in an infected abscess?
The abscess is actually a cavity under the skin, a tender mass generally surrounded by a coloured area from pink to deep red.
When you inject drugs, you may bring a germ into your injecting site, where it gets under the skin between the skin and the vein, or is accidentally pushed into glands, which causes an inflammatory response as your body’s defenses try to kill these germs.
Your body tries to seal off the infected area by creating many little ‘walls’ of pus that in turn make up a sealed off area, which will contain pus. This is formed in response to the invading germ, as white blood cells gather at the infected site and begin producing chemicals called enzymes that attack the germ by digesting it. These enzymes act like acid, killing the germs and breaking them down into small pieces that can be picked up by the circulation and eliminated from the body. Unfortunately, these chemicals also digest body tissues which is why you end up with varying degrees of a hole or ‘cavity’. In most cases, the germ produces similar chemicals. The result is a thick, yellow liquid—pus—containing digested germs, digested tissue, white blood cells, and enzymes. Some of this bacteria can still be ‘live’ which is why squeezing, poking about etc, can easily spread the infection. Your body has made this cavity in an attempt to localise the infection so it won’t spread. Clever huh? But this isolating tactic can be the reason antibiotics don’t work on their own without any attempt to also ‘cut and drain’ the site to relieve the area of the exudate or waste, without it spreading.
An abscess is the last stage of a tissue infection that begins with a process called inflammation. Initially, as the invading germ activates the body’s immune system, several events occur:
- Blood flow to the area increases.
- The temperature of the area increases due to the increased blood supply.
- The area swells due to the accumulation of water, blood, and other liquids.
- It turns red.
- It hurts, because of the irritation from the swelling and the chemical activity.
These four signs—heat, swelling, redness, and pain—characterize inflammation.
As the process progresses, the tissue begins to turn to liquid, and an abscess forms. It is the nature of an abscess to spread as the chemical digestion liquefies more and more tissue. Furthermore, the spreading follows the path of least resistance—the tissues most easily digested. This is an obvious reason why you shouldn’t poke through or squeeze your abscess because it will travel. A good example is when your abscess is just beneath the skin. It most easily continues along beneath the skin rather than working its way through the skin where it could drain its toxic contents. The contents of the abscess also leak into the general circulation and produce symptoms just like any other infection. These include chills, fever, aching, and general discomfort.
The middle of the abscess liquefies and contains dead cells, bacteria, and other debris. This area begins to grow, creating tension under the skin and further inflammation of the surrounding tissues. Pressure and inflammation cause the pain. Abscesses are often easy to feel by touching, the hotter it is usually meaning a raging infection is trying to be dealt with by your immune system; the middle of an abscess is full of pus and debris.
People with weakened immune systems or serious illness may get certain abscesses more often because the body has a decreased ability to ward off infections. Other risk factors for abscess include exposure to dirty environments, exposure to persons with certain types of skin infections, or other abscesses, poor hygiene, and poor circulation.
Most often, an abscess becomes a painful, compressible mass that is red, warm to touch, and tender.
Boils are usually pea-sized, but can grow as large as a golf ball. Symptoms can include:
- Swelling, redness, and pain
- A white or yellow center or tip
- Weeping, oozing, or crusting
- As some abscesses progress, they may “point” and come to a head so you can see the material inside and then spontaneously open (rupture).
- Most will continue to get worse without care. The infection can spread to the tissues under the skin and even into the bloodstream.
- If the infection spreads into deeper tissue, you may develop a fever and begin to feel ill. This is serious – you should seek medical treatment as soon as possible. (see the Antibiotics, Yes or No? section)
- You may also have a general feeling of ill health, fatigue, or a fever, which is reason to call a doctor.
Of special note, abscesses in the hand are more serious than they might appear. Due to the intricate structure and the overriding importance of the hand, any hand infection must be treated promptly and competently.
Unlike other infections, antibiotics alone will not usually cure an abscess because of the way it is constructed. In general an abscess must open and drain in order for it to improve. Sometimes draining occurs on its own, but generally it must be opened by a doctor in a procedure called incision and drainage (I&D). Waiting for an abscess to burst may be too painful and lancing is needed.
Or if necessary, if a head has developed on the abscess, a doctor will lance it and drain out the pus. The resulting hole should be thoroughly cleaned out, either using prescription only agents or a sterile saline solution. Since skin is very resistant to the spread of infection, it acts as a barrier, often keeping the toxic chemicals of an abscess from escaping the body on their own. This is why the pus must be drained from the abscess by a physician. who can determine when the abscess is ready for drainage and opens a path to the outside, allowing the pus to escape. Ordinarily, the body handles the remaining infection, sometimes with the help of antibiotics or other drugs. The surgeon or doctor may leave a drain (a piece of ‘wick’ cloth or rubber) in the abscess cavity to prevent it from closing before all the pus has drained out. This may not be the same as ‘packing’ of which there is conflicting evidence these days (see below).
Incision, evacuation of pus and debris, and careful probing of the cavity to break up loculations provides effective treatment of skin abscesses and inflamed skin tissue cysts. A randomized trial comparing incision and drainage of skin (cutaneous) abscesses to ultrasonographically guided needle aspiration (sucking up) of the abscesses showed that aspiration was successful in only 25% of cases overall and less than <10% with MRSA infections . Accordingly, this form of treatment is not recommended. Simply covering the surgical site with a dry dressing is usually the easiest and most effective treatment of the wound [21, 22]. Some clinicians close the wound with sutures or pack it with gauze, wick or other absorbent material, sometimes leaving it open with a wick to collect pus/exudate. One small study, found that packing caused more pain and did not improve healing when compared to just covering the incision site with sterile gauze so some clinicians are beginning to avoid this if possible.
Try and find a sympathetic doctor, go to A&E , or try a recommended needle exchange ( It will be kept confidential and some places can help with wound dressings, teaching you how to do them yourself at home.) The fear of going to your drug treatment clinic with an abscess, or to A&E, because of the effect it could have on your methadone script being changed, is unfortunately still a real one in some places/countries. But you must get advice and treatment – no matter what- because if it proceeds to get worse and is left untreated, an abscess can lead to septicaemia (blood poisoning), which can be fatal, cellulitis ( a very painful infection of the surrounding tissue) and other complications. All this will put extra pressure on your immune system – not what you want if you are HIV or Hep C positive or are rundown.
These are some things for you and your doctor to consider with a problem abscess; remember there is new information around abscess care and it is worth gently seeing if your doctor knows this (see ref below and table 2 below)
Ultrasonography may prove helpful in identifying the size and extent of an abscess
Radiography may assist in the detection of foreign bodies
Carbuncles are deeper infections involving the deep cutaneous (skin) layer and usually the subcutaneous fat
Common cutaneous abscesses include infected sebaceous cyst, infected Bartholin gland, and pilonidal abscess
Felon and paronychia are abscesses of the fingers or thumbs
Hidradenitis suppurativa is a recurrent infection of the epithelium within apocrine gland–containing skin that leads to chronic abscesses, usually in the groin or axillae
MRSA can look exactly like an ordinary abscess: red, swollen, pus-filled, and tender. But MRSA infections are caused by one particular type of staph that is resistant to many antibiotics. If a skin infection spreads or doesn’t improve after 2-3 days of antibiotics, your doctor may suspect MRSA. The right treatment given promptly is important to heal a MRSA infection and prevent a deeper, more dangerous infection.
The latest info….
Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.full
Antibiotics – yes or no?
The decision on whether to administer antibiotics directed against S. aureus, (the usual bacterium present in an abscess) as an adjunct to incision (cutting) and drainage should be made based on the presence or absence of systemic inflammatory response syndrome (SIRS) such as temperature >38°C or <36°C, tachypnea >24 breaths per minute, tachycardia >90 beats per minute, or white blood cell count >12 000 or <400 cells/µL (see Fig 2 moderate; Figure 1) (strong, low). An antibiotic active against MRSA is recommended for patients with carbuncles or abscesses who have markedly impaired host defenses and in patients with SIRS (Figure 2, Table 2) (strong, low).
Sometimes, carbuncles or abscesses are caused by methicillin-resistant Staphylococcus aureus (MRSA) bacteria, and require treatment with potent prescription antibiotics if the lesions are not drained properly. In rare cases, bacteria from an abscess can escape into the bloodstream and cause serious complications, including sepsis and infections in other parts of the body such as the lung, bones, joints, heart, blood, and central nervous system.
Sepsis is an overwhelming infection of the body that is a medical emergency and can be fatal if left untreated. Symptoms include chills, a spiking fever, rapid heart rate, and a feeling of being extremely ill.
Also read ‘The Summary’ section at end of this article.
You can usually take care of most very/small abscesses at home. Of special note, abscesses in the hand are more serious than they might appear. Due to the intricate structure and the overriding importance of the hand, any hand infection must be treated promptly and competently. Get to the doctor friends!
Warm compresses may promote the drainage and healing of abscesses. If an abscess is directly beneath the skin, it will be slowly working its way through the skin as it is more rapidly working its way elsewhere. Since chemicals work faster at higher temperatures, applications of hot compresses to the skin over the abscess will hasten the digestion of the skin and eventually result in its breaking down, releasing the pus spontaneously. This treatment should ONLY be reserved for smaller, PEA SIZED abscesses in relatively less dangerous areas of the body—limbs, trunk, back of the neck. It is also useful for all superficial abscesses in their very early stages. It will “ripen” them. Gently soak it in warm water, or apply a clean, warm, moist washcloth for 20 minutes several times per day. Similar strategies include covering the abscess with a clean, dry cloth and gently applying a heating pad or hot water bottle for 20 minutes several times per day. After each use, washcloths or cloths should be disposed of or washed in very hot water and dried at a high temperature (it is infectious remember -to you and others).
Washing and covering the area with a sterile bandage also may promote drainage and healing and help prevent the infection from spreading. Over-the-counter medications such as acetaminophen or ibuprofen can help relieve the pain of an inflamed abscess.
Contrast hydrotherapy, alternating hot and cold compresses, can also help assist the body in resorption of the abscess. There are two other remedies that work to rebalance the body in relation to some PEA SIZED abscess formations, Silica and Hepar sulphuris. In cases of TINY, PEA SIZED septic abscesses ONLY, bentonite clay packs (bentonite clay and a small amount of Hydrastis powder) can be used to draw the infection from the area.
It’s important to thoroughly wash your hands after touching an abscess. Launder any clothing, bedding, and towels that have touched it and avoid sharing bedding, clothing, or other personal items.
You must resist the urge to squeeze or pop your abscess! This can make the infection worse. Yes we know its very tempting, for some it’s downright impossible to not squeeze or poke around, but remember the scar will be bigger the more you poke and you can break that special ‘cavity’ wall and cause the infection to spread. Draining is different from squeezing, do that instead – it allows the pus to leave the site without breaking the cavity wall that has kept the abscess surrounded. Bursting is also NOT the same as draining. Squeezing and/or bursting an abscess either by itself or through you, can spread the infection and may cause complications. (see below).
If the abscess is completely drained, antibiotics are usually unnecessary but it is hard to know if it has been drained properly unless you see a doctor or nurse who should be skilled at doing it properly. But treatment with antibiotics may be necessary in cases such as:
- When MRSA is involved and drainage is incomplete
- There is surrounding soft-tissue infection (cellulitis)
- A person has a weakened immune system
- An infection has spread to other parts of the body
Tips on Preventing Abscesses
Always use new equipment – sterile water, works, swabs etc. Wash your hands before and after your fix- it is really essential you try and make this a habit – a part of your routine when injecting. Don’t use an old slimy (germy) bar soap, it is preferable to use antibacterial soap in a pump container and to let your hands and arms air dry. If you have an abscess at the current time, it is extremely important you are as clean as you can be and you use an antibacterial soap all over your body in order not to spread the infection. This is especially true when you are changing bandages. Try and do it outdoors, or over the bathroom sink/bath and dispose of all the old bandaging straight away. While a lot of the bacteria from pus is dead, some of it will be live as well and if there are other injectors around you, its important to keep everyone as free from ‘live’ bacterium as possible.
Infections that are treated early with heat (if superficial) or antibiotics will often resolve without the formation of an abscess. It is even better to avoid infections altogether by taking prompt care of open injuries, particularly injecting wounds.
Staphylococcus bacterium, the bacteria that is so often found in skin abscesses, actually lives on our skin, but will really thrive in hot sweaty areas that may not have seen a water for days. So it is really important to ensure you keep your injecting site clean, fresh and aired and you always wash your hands before handling injecting equipment, for you and any mates. And don’t let anyone hit you up without them washing their hands first as well! You wouldn’t let a nurse inject you without swabbing or putting gloves on would you?
Since bacteria are everywhere in our environments and on many people’s skin, the best defense against abscesses includes:
Hand washing or use of alcohol-based hand sanitizer
Careful cleaning of cuts, scrapes, and other wounds,
Keeping wounds covered
Not sharing towels, sheets, razors, etc.
Wash towels, sheets, and anything else in contact with an infected area in very hot water.
Throw away any wound dressings in a tightly sealed bag.
Filters: There is some debate here but generally it is assummed that one should use surgical cotton wool as ones filter because it is made up of fibres that won’t separate – unlike cotton wool, cigarette filters, tissue etc. Not only can loose fibres from these get trapped under the skin and cause an abscess , but they can also travel along your veins and cause blockages and infection in some seriously dangerous places – like your heart or get lodged somewhere along the way. This can be an extremely painful experience but fortunately, is not too common -in fact it’s pretty rare but I know someone it happened too, and it was excrutiatingly painful, the person couldn’t walk, and it was found hours later by hospital doctors, lodged in their hip (apparently). However, if you ensure to wet your filter before you use it (and don’t tear it off with your teeth or dirty nails) you will be reducing your chances of fibres dislodging or bacteria travelling to your injection site. Cut it longways, and always put the ‘shaggy’ side down in the spoon, so your syringe draws up on the smooth side. Don’t make it to small, if its wet you wont be trapping your drugs in it and you’ll have a better chance of it doing its job and ‘filtering’ your drugs of yukky bits.
There has been some very ‘dirty’ heroin going around lately, so be sure to use a good size filter and try not to miss the vein – another sure-fire way to cause an abscess.
Seconal (barbituates) and certain other tablets are notorious for causing abscesses. Usually an abscess can be all but guaranteed if you miss a vein shooting these so BE CAREFUL.
If any gear looks suspect to you, consider other ways of taking it such as snorting, smoking or swallowing. Never skin pop with suss gear and it is not recommended to skin pop or inject in the muscle with brown heroin (another sure way to get an abscess).
Speed and coke are particularly irritant to your veins and tissues, so if you can bear it- try smoking or snorting it instead. Note: it gets to the brain even faster than injecting, by smoking.
New drugs like mephedrone and incorrect steroid injections can give people some really terrible abscesses and wounds. Mephedrone is a fairly new area re abscesses but one worth looking up for more info although treatment appears to be the same however the size and look of the abscess has been thought to be worse than the usual heroin injecting related abscess.
Cleaning your own syringes properly: If you must re-use a syringe that you have previously used, attempt to disinfect a rinsed syringe by looking at the video at the end of this article.
Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America
Note -the chart below forms some of the latest US thinking on treating Skin & Soft Tissue Infections. To help you understand the lingo -in brief -Purulent means ‘contains or consists of pus’ I&D = to Incision (cut) and Drain [an abscess] C&S = Culture and Sensitivity; Rx = treatment
Where Does Your Abscess Sit on the Table of SSTI’s?
Basically: For pus producing soft tissue infections (SSTIs) – The Mild Infection stage is thought of as needing just = incision and drainage; Moderate infection is someone with purulent infection with systemic signs of infection (fever etc) – should have abscess tested for culture and any antibiotic sensitivity/resistance; Severe infection is thought of as: patients who have failed incision and drainage plus oral antibiotics or those with systemic signs of infection such as temperature >38°C, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (<12 000 or <400 cells/µL), or immunocompromised patients.
Nonpurulent SSTIs. Mild infection: typical cellulitis/erysipelas with no focus of purulence. Moderate infection: typical cellulitis/erysipelas with systemic signs of infection. Severe infection: patients who have failed oral antibiotic treatment or those with systemic signs of infection (as defined above under purulent infection), or those who are immunocompromised, or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction. Two newer agents, tedizolid and dalbavancin, are also effective agents in SSTIs, including those caused by methicillin-resistant Staphylococcus aureus,
If the abscess hasn’t been reabsorbed into the skin, it could need a bit of help to ensure the head continues to drain. You can gently push away the top of the abscess ‘lid’ with a sterile needle tip, and allow the abscess to drain. You can use a long sterile needle and roll the length of it across the top using a bit of downwards pressure, softly roll or push a bit downwards across the top area, allowing the pus and exudate to leak out. Use very clean, warm compresses to encourage more pus to LEAK, (not squeeze). Never squeeze, prod or poke or try and suck the pus out as you will spread the infection. You should see a hole and you should rinse with a gentle trickle of sterile saline solution (sterile salt water bought at any chemist or make your own).
- Put one cup of water and ½ teaspoon of salt into the pot. Put the lid on.
- Boil for 15 minutes with the lid on (set a timer).
- Set the pan aside until cooled to a room temperature.
- Carefully pour the salt and water (normal saline) from the pan into the jar or bottle and put the lid on, extract with a sterile syringe and use it as a gentle spray to clean the abscess inside.
The abscess can be covered with a bandage which should be checked daily, allowing for the fact that more pus may form and need to drain.
Note: This is for small areas of infection only. It is at this point that you should decide to go to a doctor if there is any sign of it getting worse by the day or hour. You will feel if it looks like it is getting better -any doubt will probably mean it is not healing and you must seek medical advice.
These days, the decision on whether to administer antibiotics against Staph. aureus, (the usual bacterium present in an abscess) as an adjunct to incision (cutting) and drainage should be made based on the presence or absence of systemic inflammatory response syndrome SIRS. This means if you feel any other signs such as fever, swelling of lymph areas such as groin or armpit areas, skin sloughing, fast heart beat, extreme pain, more pus, chills and feeling sick -it is urgent that you seek medical help. Your infection is in your system and is putting your immune system and bodily organs under pressure. Don’t delay.
MRSA – Interesting addition
I have included this part of a blog from http://jailmedicine.com as it provided an interesting discussion on some from our community and MRSA -in terms of repeated use of antibiotics and abscesses, definitely worth a read.
Second question–MRSA. MRSA infections are increasingly becoming resistant to the very few agents available to treat them, so I think it is especially important to apply the two rules to these infections.
- Don’t overprescribe. There is quite a lot of literature supporting the idea that you do NOT have to prescribe antibiotics following MRSA abscess I&D. The treatment for any abscess is adequate incision and drainage. You do not get any better resolution in most MRSA patients if you follow I&D with antibiotics.
- The Sledgehammer Rule. I think that it is seldom good practice to prescribe both Kelfex and Bactrim simultaneously. I know this is done outside of corrections, especially in ERs. The rationale is that without a formal culture, you are not 100% sure if this particular cellulitis is caused by methicillin resistant staph (resistant to Keflex, sensitive to Bactrim) or methicillin sensitive staph (resistant to Bactrim, sensitive to Keflex), and so, to cover all your bases, you prescribe both. However, personally, I think it is pretty easy to tell the difference between most cases of MRSA and non-MRSA infections just by looking at them. The MRSA organism is an abscess former, and so, even early on, MRSA infections tend to form an abscess or at least show a central “spider bite” core. Meth sensitive cellulitis usually does not have either. Make your best guess, maybe based on a picture the nurses send you if you are not right there, and re-evaluate as needed tomorrow or the next day. You will pick correctly 95% of the time.
Finally, what about those patients who get recurring MRSA abscesses? The patients who get recurring MRSA abscesses are typically MRSA carriers, and your goal then is to eradicate their carrier status. There are several ways to do this according to MRSA guidelines (such as these by the Infectious Disease Society of America)—here are three:
- Apply mupiricin (Bactroban) 2% ointment to both nostrils (where MRSA tends to hang out in carriers) twice a day for ten days.
- Chlorhexadine body wash once a day for 5 days.
- Rifampin 600 mg po BID for five days in addition to your primary MRSA drug, whether Bactrim or Doxycycline—don’t prescribe rifampin alone.
We are talking here about typical young healthy patients. Patients who have chronic health problems or are immunocompromised must be approached differently. The opinions here are my own. I could be wrong; feel free to disagree! (End of the Jailmedicine article)
Cellulitis— Inflammation of tissue due to infection.
Enzyme— Any of a number of protein chemicals that can change other chemicals.
Flora— Living inhabitants of a region or area.
Pyogenic— Capable of generating pus. Streptococcus, Staphocococcus, and bowel bacteria are the primary pyogenic organisms.
Sebaceous glands —Tiny structures in the skin that produce oil (sebum). If they become plugged, sebum collects inside and forms a nurturing place for germs to grow.
Septicemia— The spread of an infectious agent throughout the body by means of the blood stream.
Sinus— A tubular channel connecting one body part with another or with the outside.