Lymphedema Furuncles

Furuncles

Furuncles are actually commonly called boils. These are infections involving hair follicles and may include adjacent subcutaneous tissue. They are red, painful hot and filled with pus. Generally these localized infections are caused by staph aureus but can be caused by other bacteria or fungi. They can be either single or can appear in clusters anywhere on the skin.

It is important for the lymphedema patient not to squeeze or pick at a furuncle. The may lead to the spread of infection and can develop into erysipelas, cellulitis or lymphangitis.

Clinical:

Red tender inflammed spots

Pus filled

Painful or tender due to the infection.

According to Hopkins:

Furuncles: begins at hair follicle but becomes deeper into dermis and subcutaneous tissue. Turns to a deep seated, firm, tender nodule then abscess that enlarges. Becomes erythematous, painful and fluctuant after several days.
Most commonly affects warm, moist areas such as the neck, axillae, groin, buttocks and thighs, but may occur anywhere on hairy skin.

Differs from folliculitis which remains superficial, localized to epidermis and centered about hair follicles.

Diagnosis:

Diagnosis is generally done from simple physical examination. Although, culture and sensitivity testing may be done, it is usually not needed.

Complications:

Lymphedema patients must remember that the lymphedema limb is immunocompromised, so with any infection, even a furuncle, there is a serious possibility of the infection spreading and/or becoming serious. Therefore, furuncles require proper care, treatment and prevention.

Possible complications of furuncles can include spread of infection to other parts of the body, abscess of kidneys or other body organs, endocarditis, abscess formation and septic foci, sepsis. Other complications can include osteomyelitis, brain infection, spinal cord infection and there is risk of it becoming cellulitis, lymphangitis or turning into sepsis.

Treatment:

Generally, furuncles will heal by themselves. For more serious or deeper ones, surgical drainage may be required based upon the longevity and severity of the furuncle.

There is disagreement on the value of using topical antibiotics ointments, once the furuncle has actually formed as the infection is under the surface of the skin.

Oral antibiotics may be prescribed for more serious furuncles or for patients who are immunocompromised. These antibiotics may include trimethoprim-sulfamethoxazole, levofloxacin and/or moxifloxacin.

Groups of Individuals at Risk

As people with lymphedema, we are very at risk for any type of infection, including furuncles. Other groups include:

Those with diabetes - high blood sugar (glucose) levels can undermine a proper response by the body's immune system
Those taking certain medications - especially medications which weaken the immune system.
Patients with HIV and other diseases/conditions that weaken their immune systems
Individuals with certain skin conditions, such as psoriasis, eczema and acne.
If You are suffering from persistent furunculosis, you are recommended to go to a certified physician. Furunculosis is the process that involves repeated development of boils on the skin surface. The furuncles are boils filled with pus. The bacterium causing furuncles often stays on a permanent basis in the nasal chamber of the patients who are suffering from any form of immune disorder. Patients of HIV positive are often attacked with furuncles. In fact, repeated attacks of furuncles are an indication of occurrence of the wearing out disease called diabetes.

Prevention:

There are a number of steps you can undertake to lesson your risks of developing a furncle, these include:

Keep your skin clean by washing it regularly. Use a mild antibacterial soap.
All skin wounds, cuts, and grazes should be immediately cleaned, no matter how small they are.
A sterile bandage over the cut will help prevent infection
Regular physical exercise will improve your general health and your immune system, reducing your risk of developing boils
A healthy, well balanced diet will also reduce your chances of developing boils

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Furuncles

Furuncles are skin abscesses caused by staphylococcal infection, which involve a hair follicle and surrounding tissue. Carbuncles are clusters of furuncles connected subcutaneously, causing deeper suppuration and scarring. They are smaller and more superficial than subcutaneous abscesses (see Bacterial Skin Infections: Cutaneous Abscess). Diagnosis is by appearance. Treatment is warm compresses and often oral antistaphylococcal antibiotics.

Both furuncles and carbuncles may affect healthy young people but are more common in the obese, the immunocompromised (including those with neutrophil defects), the elderly, and possibly those with diabetes. Clustered cases may occur among those living in crowded quarters with relatively poor hygiene or among contacts of patients infected with virulent strains. Predisposing factors include bacterial colonization of skin or nares, hot and humid climates, and occlusion or abnormal follicular anatomy (eg, comedones in acne).

Furuncles are common on the neck, breasts, face, and buttocks. They are uncomfortable and may be painful when closely attached to underlying structures (eg, on the nose, ear, or fingers). Appearance is a nodule or pustule that discharges necrotic tissue and sanguineous pus. Carbuncles may be accompanied by fever and prostration.

Diagnosis is by examination. Material for culture should be obtained from patients with single furuncles on the nose or central face, from patients with multiple furuncles, and from immunosuppressed patients.

Treatment of a single lesion is intermittent hot compresses to allow it to point and drain spontaneously. A patient with a furuncle in the nose or central facial area or with multiple furuncles or carbuncles is given a penicillinase-resistant beta-lactam (dicloxacillin or cephlalexin 250 to 500 mg po qid. Use of initial empiric therapy against MRSA is not typically advised unless there is compelling clinical evidence (eg, contact with a documented case or outbreak; high culture-documented prevalence in a practice area). If resistant strains or complicated infection is clinically suspected, alternate empiric choices include trimethoprim-sulfamethoxazole, levofloxacin and moxifloxacin. Systemic antibiotics are also needed for larger lesions, lesions that do not respond to topical care, evidence of expanding cellulitis, immunocompromised patients, and patients at risk of endocarditis.

Systemic antibiotics are also needed for larger lesions, lesions that do not respond to topical care, evidence of expanding cellulitis, immunocompromised patients, and patients at risk of endocarditis.

Incision and drainage are occasionally necessary and are indicated to speed resolution when the furuncle or carbuncle is fluctuant.

Furuncles frequently recur and can be prevented by applying of liquid soap containing either chlorhexidine gluconate with isopropyl alcohol or 2 to 3% chloroxylenol by giving maintenance antibiotics over 1 to 2 mo. Patients with recurrent furunculosis should be treated for predisposing factors such as obesity, diabetes, occupational or industrial exposure to inciting factors, and nasal carriage of Staphylococcus aureus or methicillin-resistant S. aureus (MRSA) colonization.

Last full review/revision October 2007 by A. Damian Dhar, MD

Content last modified October 2007

Merck

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Furuncles

Paul Auwaerter, M.D. and Ciro R. Martins, M.D.
09-06-2007

PATHOGENS

Staphyloccocus aureus
Cutaneous abscesses often polymicrobial while true furuncles and carbuncles are due to S. aureus.

CLINICAL

Furuncle: begins at hair follicle but becomes deeper into dermis and subcutaneous tissue. Turns to a deep seated, firm, tender nodule then abscess that enlarges, becomes erythematous, painful and fluctuant after several days.
Most commonly affects warm, moist areas such as the neck, axillae, groin, buttocks and thighs, but may occur anywhere on hairy skin.
Differs from folliculitis which remains superficial, localized to epidermis.
Carbuncle: deeper and wider lesions with interconnecting subcutaneous abscesses arising from infection of several neighboring hair follicles. Multiple draining sinuses may develop into ulcers that heal with scarring. Carbuncles are common on the nape of the neck.
Surrounding cellulitis and systemic symptoms including of fever and malaise may be present (more often seen with carbuncles).
Community-acquired MRSA: clones that causes severe and recurrent furunculosis sometimes associated with cellulitis and described as causing and less frequently necrotizing fasciitis. Usually needs surgical drainage.
Ddx: epidermoid ("sebaceous") cyts with cheesy material often with skin flora even if uninflamed, erythema nodosum, other forms of panniculitis, arthropod bite hypersensitivity reaction, vasculitis, mycobacterial infections, cutaneous B- or T-cell lymphomas.

DIAGNOSIS

Clinical diagnosis.
Culture and sensitivity testing are usually not necessary if routine I&D required. Obtain if planning systemic therapy (e.g., fever, significant cellulitis, hospitalization) or concern for CA-MRSA outbreak.

TREATMENT

General Management / Topical Care

Moist heat (compresses) or hot packs tid-qid till drainage or resolution. This alone may be sufficient for small furuncles.
Surgical incision and drainage necessary for large furuncles and carbuncles when fluctuation is palpable or lesions point. Evacuation of pus with thorough probing to break loculations and remove all inflammatory material.
Systemic antibiotics are usually unnecessary unless fever or significant surrounding cellulitis present.
After drainage, wash area w/ antiseptic/antibacterial soap. followed by application of Mupirocin 2% ointment bid.
Keep the area covered with gauze until wound closes.
Topical care usually curative for single lesions not associated with cellulitis or systemic symptoms.
"Community-acquired MRSA:" clones that causes severe and recurrent furunculosis sometimes associated with cellulitis and described as causing necrotizing fasciitis. Usually needs surgical drainage.
Most strains are sensitive to TMP-SMX, rifampin, clindamycin and doxycycline.

Systemic Therapy--adult

Indicated only in cases with associated systemic symptoms (e.g., fever) or extensive cellulitis.
Choices often made without benefit of culture, and therefore often default to MRSA choices.
Community-acquired MRSA strains often susceptible to TMP-SMX, tetracyclines, clindamycin if oral therapy considered. Fluoroquinolone susceptibility possible but not reliable.
Severe (MRSA): vancomycin 15mg/kg IV q12h, linezolid 600mg IV/PO q12h, daptomycin 4mg/kg IV q24 (6mg/kg w/ bacteremia), tigecycline 100mg IV loading dose followed by 50mg IV q12h , clindamycin 600mg IV q8h (if susceptible).
Mild-moderate (MRSA): TMP-SMX 1-2 PO twice daily , doxycycline or minocycline 100mg PO twice daily , clindamycin 300-450mg PO q8h--all depending on susceptibilities.
Unclear with mild to moderate infections (with sufficient drainage) that discordant treatment if MRSA positive leads to poor outcomes (see Fridkin reference)
Severe (MSSA): nafcillin or oxacillin 1-2g q4h, cefazolin 1g IV q8h, clindamycin 600mg IV q8h.
Mild-moderate (MSSA): dicloxacillin 500mg PO qid, cephalexin 500mg PO qid, doxycycline or minocycline 100mg PO bid or clindamycin 300-450mg PO tid.

Recurrent Furunculosis

Treatment goal: eradicate chronicS. aureus carriage and potential fomite transmission. Little good clinical data to guide recommendations.
Often described in settings of close personal contact: families, sexual partners, sports teams. Personal hygiene and contact with individuals suffering from furunculosis are important risk factors.
Recurrent furunculosis is not thought to represent an immune deficiency in most individuals, but why some colonizers are afflicted with boils and others not is unclear. May rarely represent host immune deficiency (e.g., CGD) in some children.
Use nasal swab to assess for S. aureus carriage, presence of MRSA and guide abx selection (if necessary).
General measures: antiseptic soaps such as chlorhexidine or hexachlorophene [apply to all intact skin, let stand for 2-5 minutes and then rinse: perform daily to several times/week]; loose-fitting clothes; frequent changes of underwear and linens; avoidance of trauma/irritation of skin.
Use 10% dilute bleach to disinfect all bathroom surfaces (tub, floor, sink, toilet).
Topical nasal carriage application: mupirocin (Bactroban) nasal, ½ tube each nares bid or 2% ointment bid x 5d. May repeat the first 5d of every month. May reduce recurrence rate ~50%.
Systemic (if above measures fail): clindamycin 150mg PO daily x 3 months (preferred, offers ~80% reduction in rate), TMP-SMX 1 DS PO daily x 3 mos, doxycyline100mg PO daily x 3 months.
Combination of nasal mupirocin, chlorhexidine washes, doxycycline 100mg PO bid + rifampin 600mg PO daily all for 7d, may offer shorter course of therapy to decrease recurrent furunculosis (see Simor reference).

OTHER INFORMATION

Local predisposing factors (recurrent furunculosis): hyperhidrosis, poor hygiene, constant friction and pressure, ingrown hairs.
Systemic predisposing factors (recurrent furunculosis): obesity, blood dyscrasias, malnutrition, immunodeficiency, diabetes, chronic dialysis, IV drug abuse.

John Hopkins

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External Links

Furuncle

http://www.medical-library.org/journals2a/furuncle.htm

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Furuncle

http://www.nlm.nih.gov/medlineplus/ency/article/001474.htm

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Furuncle

http://www.umm.edu/ency/article/001474.htm

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Furuncles and carbuncles

Skin abscesses, furuncles, and carbuncles

http://www.uptodate.com/contents/skin-abscesses-furuncles-and-carbuncles

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Diagnostic Images

Google

http://images.google.com/images?hl=en&q=furuncles&gbv=2

Yahoo

http://images.search.yahoo.com/search/images?p=furuncles&fr=yfp-t-501&toggle=1&cop=mss&ei=UTF-8

DermnetNZ

http://www.dermnet.com/thumbnailIndex.cfm?moduleID=3&moduleGroupID=53&groupIndex=0&numcols=0

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Diagnostic Codes and External Resources

L02	Cutaneous abscess, furuncle and carbuncle
	Includes:	boil furunculosis
	Excludes:	anal and rectal regions ( K61.- ) genital organs (external): · female ( N76.4 ) · male ( N48.2 , N49.- )

L02.0		Cutaneous abscess, furuncle and carbuncle of face
		Excludes:	ear, external ( H60.0 ) eyelid ( H00.0 ) head [any part, except face] ( L02.8 ) lacrimal: · gland ( H04.0 ) · passages ( H04.3 ) mouth ( K12.2 ) nose ( J34.0 ) orbit ( H05.0 ) submandibular ( K12.2 )

L02.1	Cutaneous abscess, furuncle and carbuncle of neck
L02.2	Cutaneous abscess, furuncle and carbuncle of trunk
	Abdominal wall Back [any part, except buttock] Chest wall Groin Perineum Umbilicus
	Excludes:	breast ( N61 ) hip ( L02.4 ) omphalitis of newborn ( P38 )

L02.3	Cutaneous abscess, furuncle and carbuncle of buttock
	Gluteal region
	Excludes:	pilonidal cyst with abscess ( L05.0 )

L02.4		Cutaneous abscess, furuncle and carbuncle of limb
		Axilla Hip Shoulder

L02.8		Cutaneous abscess, furuncle and carbuncle of other sites
		Head [any part, except face] Scalp

L02.9		Cutaneous abscess, furuncle and carbuncle, unspecified
		Furunculosis NOS

2008 ICD-9-CM Diagnosis 680.9

Carbuncle and furuncle of unspecified site

680.9 is a specific code that can be used to specify a diagnosis
680.9 contains 11 index entries
View the ICD-9-CM Volume 1 680.* hierarchy

680.9 also known as:

Boil NOS
Carbuncle NOS
Furuncle NOS

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