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Three Part Question

In [a patient with an abscess] does [packing the wound or not packing the wound] [affect healing time?]

Clinical Scenario

A 32 year old man attends casualty with a large abscess on his bottom, painful and ready to burst. You wonder whether you should pack the abscess after draining it. He is self-employed and needs to get back to work quickly.

Search Strategy

Medline using the OVID interface 2004-present
Embase using the OVID interface 2004-present

[exp abscess/ OR exp furunculosis/ OR furuncle.mp. OR exp carbuncle/] AND [exp wound healing/ OR wick.mp. OR drain.mp. OR recover.mp.]

Search Outcome

A search of Embase and Medline gave a total of 1589 papers, 3 of which were relevant to the question. A further search of the Cochrane Library of Systematic Reviews was also performed with the use of keywords as the [exp] search term is not valid for this particular database. This gave a total of 67 papers, none of which were relevant to the question.

Additionally there was 1 ongoing interventional trial located on the National Institute for Health website: www.clinicaltrials.gov. Trial numbers: NCT01698996 which may provide additional future evidence.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kessler et al. 2012 New York, USA	57 patients aged 1-24 with skin abscesses requiring I&D. 22 had packing and 27 had no packing (8 lost to follow-up)	Prospective Randomised Single Blind Controlled Trial	Major or minor treatment failure*	No statistically significant results in either group except the packing group requiring more wound packing!	"Small study size with no statistically significant results (p values not published however). Underpowered to detect any differences.
			Major = serious requiring repeat I&D or re-exploration of the wound. Minor = less serious, i.e. need for antibiotics, additional wound packing or repeat visit
			Pain at baseline, post-procedure and 48h follow-up	No difference in groups
O'Malley et al. 2009 Philadelphia, USA	48 patients aged 18 or older with cutaneous abscesses located on the trunk or extremities that required I&D.23 had wound packing, 25 had no packing	Prospective Randomised Single Blind Controlled Trial	Need for intervention at 48 hours ¢	No difference between groups	Very small study size with only 66% attending 48h follow-up. Large numbers of exclusion criteria limit applicability to general population.
			¢ Intervention defined as: extension of previous incision, further probing to break up loculations, irrigation, packing the wound, change of antibiotics, need for surgical evaluation, admission to hospital or need for a follow-up visit to the ED.
			Description of pain & amount of pain medication used over 48 hour period	No difference in pain description. Packing group took more oxycodone/acetaminophen than non-packing (0.91 vs. 3.1)
Tonkin et al. 2004 Australia	50 patients with perianal abscesses drained under GA, 20 allocated to wound packing and 23 to non-packing (7 lost of follow-up)	Prospective Randomised Single Blind Controlled Trial	Complete wound healing	Packing - 24.5 days (10-150) Non-packing - 21 days (8-90) No significant difference. "	"Small sample size - most results not statistically significant. A small number of abscesses took a very long time to heal and thus gave huge confidence intervals. Potentially not generalisable to patients receiving drainage in the ED under LA as more thorough drainage can be achieved under GA."
			Recurrence of abscess, pain scores and analgesia usage.	No significant difference in recurrence. Lower reported pain scores and analgesia usage in non-packing group

Comment(s)

The updated literature on this topic suggests that there is no significant difference between packing and non-packing an abscess that has been incised and drained. The older literature, despite having more patients is not high quality and some studies are inherently flawed. A large multi-centre blinded clinical trial is needed to answer this question completely. There is evidence that not-packing an abscess is less painful and, although not mentioned in any of the newer literature, is likely to be less expensive than packing.

Clinical Bottom Line

The evidence cannot recommend packing or not packing an abscess - the decision remains a personal clinical one.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Kessler, David O., Amanda Krantz, and Michael Mojica Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department Pediatric Emergency Care 2012; 28.6: 514-517
2. O’Malley, Gerald F., et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary Academic Emergency Medicine 2009; 16.5; 470-473
3. Tonkin, Darren M., et al. Perianal abscess: a pilot study comparing packing with nonpacking of the abscess cavity Diseases of the Colon and Rectum 2004; 47.9: 1510-1514