*On average, patients experienced significantly increased pain in the groups undergoing packing; the average increase in pain due to packing was 24mm (VAS) during the procedure.
Source: O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med 2009;16:470-473.
Barnes SM and Milsom PL. Abscess: an open and shut case. Arch Emerg Med 1988;5:200-205.
Efficacy Endpoints: Prevention of need for secondary intervention (for example, repeat incision and drainage); prevention of recurrent abscess
Harm Endpoints: Pain during packing/removal of packing
Narrative: The management of abscesses has classically included incision and drainage of the lesion followed by the insertion of packing material into the cavity. Patients are typically told to return to the ED 48 hours later, at which point the packing is removed and, occasionally, new packing inserted. Multiple textbooks support this approach and describe packing as critical in preventing recollection of pus. It is believed that packing absorbs pus and debris and prevents premature closure of the incision, leaving a route of egress for pus.
Surprisingly, there is only one randomized, controlled trial evaluating the utility of packing in simple cutaneous abscesses managed in the ED setting1. The sample size is small (n = 48), the methods are good, and outcome assessments were blinded. Of note, all subjects were prescribed antibiotics. At 48 hours, 17% in the packing group and 20% in the nonpacking group received a secondary intervention (p = 0.72), although use of these interventions was left to judgment and most were of questionable clinical utility.
In this study pain scores were evaluated, with an average difference in pain scores post-procedure and at two days of 23.8 mm (95% CI, 5-42 mm) and 16.4 mm (95% CI, 1.6-31.2 mm), respectively, in favor of not receiving packing.
Caveats: These data include only one small trial. However there are many studies in the surgical literature of varying quality indirectly assessing the utility of packing in cutaneous abscesses. An informal review of observational and trial data (n =1943) evaluating a ‘closed’ versus ‘open’ technique for abscess treatment found the closed approach yielded faster healing and no difference in recurrence. In the closed approach, incision and drainage is performed and sutures placed to close the wound. The open technique included packing. While all types of abscesses were included in this review, they were drained under general anesthesia and all patients received one dose of intravenous antibiotics during the procedure, suggesting that the abscesses in these data were larger and more complex than those seen in most outpatient settings. This may limit the applicability of these results to the ED setting, although the less complex nature of most abscesses suggests that most abscesses are even less likely to benefit from packing than those evaluated in observational data. These data therefore support the findings of the one trial, suggesting that packing after abscess drainage, a classically recommended practice that was not based on evidence but rather based on theoretical concerns, may lead to increased pain without any corresponding benefit.
Author: Ashley Shreves, MD
Published/Updated: December 23, 2010
The title bar is color-coded with our overall recommendation.