Note, this post doesn’t tackle the loop drainage versus traditional incision and drainage question. I’ll tackle that elsewhere. This post does however, attempt to answer the question of whether or not you should pack an abscess following incision and drainage. And look, when I was first taught how to drain an abscess I was taught to pack them 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. In the past several years, I began to reconsider based on a review of the literature and experience at the bedside. A relatively recent survey of 350 Emergency Department providers revealed that 91% of respondents routinely packed abscesses – I wonder if many of them have asked the same questions I did about how we perform this procedure, and whether or not packing is necessary.

Take home point: You probably don’t need to pack most abscesses in children after I&D

OK, so how does one actually pack an abscess?

After incision, drainage and probing +/- irrigation the goal of packing is to theoretically prevent closure of the wound margins and thus reaccumulation of pus. Too loose and you defeat the purpose and just risk increasing pain, too tight and you can cause tissue necrosis. You can pack with strips of sterile gauze, iodoform gauze, or a silver-containing hydrofiber (like Aquacel). You should leave at least a 1cm tail outside of the cavity as a wick to facilitate drainage and to allow for much, much easier removal. You leave the wound open with a dressing covering it. P{patients then follow up with their doctor or at an appropriate provider (even back at the ED if necessary) for a “wound check” and to have the packing removed. If out falls out too early you probably didn’t pack it correctly in the first place – or perhaps the patient pulled it out “accidentally.” The downside is that packing an abscess takes longer, it can increase pain, and possibly increase the risk of tissue necrosis.

So, should we be packing abscesses in the first place?

Let’s take a look at some of the evidence – including three studies presented here in chronological order.

Routine packing of simple cutaneous abscesses is painful and probably unnecessary
O’Malley et al., 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 et al., 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

Incision and drainage of subcutaneous abscesses without the use of packing
Leinwald et al., J Pediatr Surg, 2013

  • RCT of 85 children who underwent I&D for a cutaneous abscess – 43 were randomized to packing and all got 7 days of oral antibiotics active against MRSA
  • Pilonidal and perianal abscesses were excluded, the mean abscess diameter was 5-6cm
  • Each group had a MRSA prevalence in the mid 80% range
  • Ultimately the two groups were similar with respect to initial characteristics and MRSA prevalence and there were only 1 recurrence in each group (2.3% vs 2.4%)

So, in conclusion…

These three 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 and with ultrasound. 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 are their own special thing. I stopped packing most all of my abscesses 7-8 years ago and have noted no significantly increased rate of return to the ED or complications from patients. I do call families after select procedures to see how they are doing – this is a great way to improve your practice by the way.

Also loop drainage is great… Learn how to do it.

References

Kessler et al. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department, Pediatr Emer Care, 2012.

Leinwald et al., Incision and drainage of subcutaneous abscesses without the use of packing. J Pediatr Surg, 2013.

O’Malley et al., Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med, 2009.