When I was first taught how to drain an abscess I was taught to pack most with ¼ inch gauze. Initially it was iodoform gauze, later just plain old ribbon gauze. As with many things I felt like it worked and had no impetus to change. Recently, I began to reconsider based on a review of the literature and experience at the bedside. A recent survey of 350 Emergency Department providers revealed that 91% of respondents routinely packed abscesses – I wonder if many of them are asking the same question about how we perform this procedure, and why there seems to be so much heterogeneity.
So, should we be packing abscesses? Let’s take a look at the evidence.
Routine packing of simple cutaneous abscesses is painful and probably unnecessary
O’Malley, Acad Emerg Med, 2009
- RCT of 48 adults with skin abscesses <5cm
- Excluded pilonidals and hidraadenitis suppartiva
- Packed wounds reported more pain 48 hours later and didn’t require more repeat I&Ds (17.4% vs 20%, RR 0.77; 95% CI 0.24-2.5)
- Patients in the packing subgroup took a little more than two extra percocet pills than the non-packed group
Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department
Kessler, Pediatr Emer Care, 2012
- Sterile gauze vs no packing in 56 patients, mean age 18 (85% were <5cm)
- Pain was not significantly different immediately post procedure or at 48 hours
- Also, no significant difference at 48 hours in need for repeat I&D or wound exploration by clinician blinded to initial treatment
So, these two studies seem to suggest that in smaller abscesses there is probably no definite benefit to packing, and patients may have more pain. It is also important to accurately assess the size of the diameter of the abscess. It is the actual size of the cavity – not just the redness on the surface of the skin. We can only assess the size in many cases during exploration of the cavity.
Also, I cannot conclude that all abscesses should not be packed. I think that those greater than 5cm may still benefit, especially if the patient has good follow up. And, of course, pilonidal abscesses and hidradenitis supportiva are totally different entities and their management differs accordingly.