Boils and carbuncles

A boil (furuncle) starts as a painful pink or red bump. Over the next few days the swelling and inflammation increases and the boil fills with pus – it can be pea-sized or larger. A yellow or white tip develops and eventually the boil ruptures and drains. Small boils can heal without scarring; larger ones can leave a scar or patch of discoloured skin.

Common sites for boils include hair-bearing areas of the face, neck, axillae, buttocks, groin and the anogenital region.

Carbuncles are clusters of boils. They appear as tender, multiple abscesses discharging pus from several points with inflammation of surrounding tissue. The patient may have a fever and feel systemically unwell. Common sites for carbuncles include the back of the neck, shoulders, hips and thighs. There is a risk of secondary infection (e.g. cellulitis).

The management of boils, carbuncles, staphylococcal paronychia and whitlows depends on whether they appear to contain a large collection of pus or not. For small boils, management comprises the application of moist heat three to four times a day and analgesics (ibuprofen or paracetamol). This relieves discomfort and helps to bring them to a head so that they drain spontaneously.

If the lesions contain a large amount of pus (a fluctuant mass) they may be incised and drained by a suitably experienced practitioner. Moist heat and analgesics will also be helpful. Antibiotic treatment is only indicated if the patient has a fever, comorbidities, or the boil is on the face or if the lesion is very large.³ Patients should be advised not to squeeze the lesions or attempt to incise and drain them.

Spontaneously discharged lesions should be covered with a dressing to prevent spread of infection. Good personal hygiene (hand washing; using separate towels) is essential to avoid spreading the infection to other areas of the body or to other people.

Patients who suffer from recurrent bacterial folliculitis or boils may be colonised with Staphylococcus aureus and can benefit from decolonisation. This can only be undertaken once an acute episode is over. Staphylococcus aureus carriage is established by culture of swabs from the groin, axillae and nose.

For elimination of nasal carriage, application of Naseptin four times a day for 10 days or mupirocin three times a day for five days is recommended.

For elimination of skin carriage an antiseptic preparation (such as chlorhexidine 4% body wash/shampoo or Triclosan 2%, Hibiscrub or Hydrex) used daily for five days as liquid soap in the bath, shower or sink is recommended.³ The Dermol product range (emollient and wash products) is an alternative for delicate skin.

In addition, the following general hygiene measures to prevent further reinfection should be recommended:

• Take a daily shower or bath
• Wash hands regularly with soap and water
• Change clothes and underclothes regularly
• Avoid sharing towels, face cloths, razors, toothbrushes and water bottles
• Wash sports clothes after use each time
• Use disposable tissues to blow the nose (and avoid picking it!)
• In saunas and gyms, sit on a clean towel and wash the towel after use.