Week 6 - Abscesses, furuncles, boils, carbuncles, pilonidal cyst Flashcards
What are Furuncles, Carbuncles, Abscesses or Boils?
Walled-off collection of pus
Red, hot, tender, firm, or fluctuant mass
Cellulitis may precede or occur in conjunction with it.
Furuncles are uncommon in children, but increase in frequency after puberty.
Where do Abscesses arise?
Abscesses often arise from traumatic inoculation of bacteria into the skin.
Where do Furuncles arise?
Furuncles arise from infected hair follicles.
What are PE findings for Abscesses?
Deep, tender, firm, red papule that enlarges rapidly into a tender deep-seated nodule.
Typically stable and painful for days and then becomes fluctuant.
Cavity contains a surprisingly large quantity of pus and white chunks of necrotic tissue.
Usually normal body temperature and no systemic symptoms
Pain becomes moderate to severe as purulent material accumulates.
Pain is most intense in areas where expansion is restricted, such as the neck and external auditory canal.
It either remains deep and reabsorbs or points and ruptures through the surface.
The point of rupture heals with scarring.
Treatment options of Furuncle?
Many are self-limiting or respond to moist warm compresses, or alternating hot/cold.
Principal therapy is still INCISION and DRAINAGE (I&D)!
How do you I&D a furuncle?
- Anesthetize the skin using more lidocaine than usual.
- Open the lesion with a #11 scalpel, wear eye protection!
Incision choices: A “cruciate” incision or a linear incision
What are Pilonidal Cysts?
An abnormal pocket in the skin that usually contains hair and skin debris.
Almost always located near the tailbone at the top of the cleft of the buttocks.
Typically hair punctures the skin and then becomes embedded.
What is the etiology of Pilonidal Cysts?
Congenital predilection for the hairy person with a deep congenital postanal dimple and a deep intergluteal cleft.
Hairs, lying loose on the skin, are drawn into the dimple and the deeper tissues by negative suction caused by movement of the buttocks.
Acquired factors for Pilonidal Cysts?
Obesity
Hot, humid environments, e.g. “big rig” driver
Irritation to the area, e.g. horseback riding, tight clothing
Sitting for prolonged periods of time
Incidence and occurrence of Pilonidal Cysts?
Incidence:
Most common in young adults
Occurrence:
most frequently in Caucasians
rarely in African Americans
practically never in Asians.
Findings with Pilonidal Cysts?
Often extremely painful bacterial abscess - commonly infected with E. coli, P. aeruginosa, or S. faecalis
Draining sinus in midline
Usually a secondary opening, almost always 2.5-5 cm (1- 2 in.) cephalad and to one side od the midline
Mouth of the opening lined by granulation tissue, typically with protruding hairs
Induration may be palpable between the two orifices.
DDX Pilonidal Cysts?
Furunculosis and anal fistulae are not typically midline.
Most pilonidal cyst primary openings are in the midline.
If the secondary opening lies inferiorly near the anus instead of in the usual cephalad site, the following may help to confirm a pilonidal cyst:
No induration between the most anterior sinus and the anus
No internal anal fistulous opening
A probe inserted gently into the anterior sinus passes upward toward the sacrum, not toward the anal canal (as in an anal fistula).
Treatment of Pilonidal Cysts?
There is a high recurrence rate and many different operations are recommended, which indicates that results are often less than satisfactory with any and all treatments!
Conservative Tx Pilonidal Cysts?
NOTE: The simplest forms of home treatment often best:
Loose weight if needed.
Keep the area clean – daily, gentle washing with washcloth
Carefully remove any protruding hair on a regular basis.
Avoid tight clothing.
Hot water baths/compresses, tea bag compresses or alternating hot and cold may spontaneous drainage!
Potato, carrot, etc. poultices
Zinc, multivitamin supplements
Hepar sulphuris homeopathic
Oral antimicrobials or antibiotics added to the home remedies may still not be enough to heala pilonidal cyst short of surgery!
Surgical Tx for Pilonidal Cysts?
- Incision and drainage:
Preferred surgical technique for a new pilonidal cyst.
Perform I & D, curette away the granulation tissue as necessary, remove the hair follicles and pack the cavity with iodoform gauze.
Advantage – simple procedure done under local anesthesia
Disadvantage – frequent changing of gauze packing until the cystheals, sometimes up to three weeks time
2.Incision and drainage with immediate closing of the wound:
Advantage – wound is completely closed immediately following surgery without need for gauze packing
Disadvantage – high rate of recurrence - the cyst walls are still present!
3.Marsupialization:
Procedure - incision and draining, removal of pus and hair, and sewing of the edges of the fibrous tract to the wound edges to make a pouch.
Advantages:
Outpatient surgery under local anesthesia
Minimizes the size and depth of the wound without the need to pack wound with gauze
Disadvantages:
Needs a surgeon trained in the technique.
Is usually a hospital procedure.
Requires about six weeks to heal
- Drainage of an Existing Tract:
Performed as an office procedure.
Technique:
Infiltrate with local anesthesia.
Shave the area.
Excise the midline pits and the lateral sinus opening(s) by elliptical incisions.
Remove all hair, debride/curette the tract.
Repeat debridement and curettage at regular intervals until healed (closes by second intention).
