ABSTRACT
Abscesses account for >50% of physician visits related to skin and soft tissue infections (SSTIs). Incision and drainage (I&D) is the mainstay of therapy, along with adjunctive antibiotic. This topic addresses indications, contraindications of incision and drainage for skin and soft tissue abscesses.
Resources provided by this topic include:
- Techniques for incision and drainage of abscess
- Indications and contraindications
- Complications
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Step-by-step protocols
- Documentation requirements
CLINICAL
Overview
Abscesses account for >50% of physician visits related to skin and soft tissue infections (SSTIs).[1] Incision and drainage (I&D) is the mainstay of therapy, along with adjunctive antibiotic.[1] This topic addresses indications, contraindications of incision and drainage for skin and soft tissue abscesses.
Background
Definitions
- Conventional incision and drainage: Incision and drainage (I&D) is a widely used procedure in various care settings, including emergency departments and outpatient clinics. It is the primary treatment for skin and soft tissue abscesses, with or without adjunctive antibiotic therapy.[2][3] The procedure is described as the mechanical task of introducing a sharp sterile instrument into a discrete subcutaneous collection of pus, blood or other fluid for the purpose of removing from the lesion said pus, bacteria, blood, necrotic tissue, or other toxins, to promote resolution of infection, inflammation, and pain or to obtain material for diagnostic analysis. [4][5] It is often performed by a single clinician and can be guided by ultrasonography.[6]
- Soft tissue abscess:
- Soft tissue abscesses refer to a non-necrotizing infection of the skin that additionally may involve subcutaneous tissue.[7]
- An abscess is a circumscribed collection of pus of any size in any location, and as such represents an infection. Abscesses usually exhibit one or more of the following clinical findings: redness, warmth, tenderness, fluctuance, edema, lymphangitis. A lesion not exhibiting such signs or symptoms and that does not contain pus or infected purulent fluid is not an abscess, but may be some other type of process requiring incision and drainage such as a hematoma, seroma, bulla or cyst. [4]
- For documentation and coding purposes, abscesses can be classified as simple or complicated.[4] Complexity of an I&D is determined by the provider.[8] Below are some examples of simple and complicated abscesses [4][8]:
- Simple abscess: a simple abscess generally requires only a single puncture or single incision.
- Complicated abscess: a complicated abscess with infection and necrosis usually requires more effort to treat. Examples of complicated abscesses are the following: an abscess with 3-4 tracks requiring breaking up of loculated compartments; an abscess requiring undermining of the skin and subcutaneous tissue and extensive laying open of the cavity; an abscess requiring wound packing, drain insertion and/or probing. In these circumstances, at minimum, locally injected anesthesia is usually required.[4] Multiple skin or subcutaneous incision and drainage during the same encounter are coded as complicated, rather than coding multiple simple incision and drainage.[8]
Relevance
- Incision and drainage is the primary treatment for skin and soft tissue abscesses, which represents nearly half of the six million visits to the emergency departments in the United States for skin and soft tissue infections.[5][9]
Care Setting
- Incision and drainage can be performed in various care settings, including urgent care centers, emergency departments, or outpatient clinics.
Scope of Practice
INCISION AND DRAINAGE
- Incision and drainage is is typically performed by medical doctors (MD), doctors of osteopathic medicine (DO), nurse practitioners (NP), or physician assistants (PA). Podiatrists are limited in scope of practice by State law.[4]
Techniques for incision and drainage (I&D)
This topic focuses on the conventional incision and drainage technique but other techniques are also listed below for comparison purposes:
- Loop drainage technique (LDT): consists in abscess drainage through a less-invasive alternative. The LDT involves making a small incision at each pole of the abscess, breaking up loculations, and placing a vessel loop through the incisions that is tied at the skin surface.[10] The vessel loop can facilitate continued drainage from the abscess cavity while using smaller incisions and reducing follow-up visits for wound checks. If the abscess is large, multiple vessel loops can be placed to span the entire abscess cavity. Vessel loops do not need to be changed or replaced.[11] A systematic review and meta-analysis found that LDT was associated with reduced treatment failures when compared with conventional incision and drainage.[5]
- Ultrasound-assisted incision and drainage: the technique of incision and drainage with point-of-care ultrasonography involves using ultrasonographic images obtained before the procedure. The ultrasonographic imaging is performed by clinicians with experience in soft tissue ultrasonography. The images are used to guide the incision and drainage of the abscess. This technique is compared to the traditional method of performing incision and drainage based on physical examination alone. In some cases, additional ultrasonographic imaging is performed during or after the incision and drainage at the discretion of the clinician performing the drainage.[6] A randomized controlled trial with 125 patients concluded that patients with soft tissue abscesses undergoing incision and drainage with point-of-care ultrasonography demonstrated less clinical failure (i.e. need for repeated incision and drainage) compared with those treated without point-of-care ultrasonography.[6]
- Wound packing: traditionally, after incision and drainage of the abscess, the wound is packed with gauze, swab or alginate dressing in order to not only allow healing by secondary intention but also prevent an early recurrence.[12] However, a systematic review and meta-analysis concluded that it is safe and effective to perform incision and drainage of subcutaneous abscesses without the placement of packing material.[12] This is because packing removal can be associated with increased pain and potential noncompliance in packing removal can lead to infectious complications.[12]
Understanding Relevant Anatomy
The 3 layers of the skin are: epidermis, dermis, and subcutaneous fat layer or subcutis (Figure 3). For details, see section 'Skin Appendages and Nerves' in topic "The Skin".
- Cutaneous abscesses are localized collections of pus that occur within the dermis and subcutaneous space. They can occur virtually anywhere on the body, but common locations for an abscess to develop are the groin, buttocks, axillae, and extremities.
General Indications and Contraindications
Indications
Indications for incision and drainage are:
- Drainage of abscesses (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, post-operative wound infections, or paronychia).[4]
- Drainage of hematomas, seromas, cysts or other pathologic fluid collections causing pain, inflammation or infection. [4]
Contraindications
Potential contraindications for bedside incision and drainage are:
- Soft tissue infection without palpated fluctuance (i.e., skin feel indurated and there is no feeling of fluid underneath the skin). Those cases might benefit from a trial of antibiotics without the need for incision and drainage. Some soft tissue infection without palpated fluctuance might benefit from ultrasound imaging to assess presence of collection. Necrotizing fasciitis should always be a differential diagnosis.
- Abscesses whose incision and drainage may require more resources than available at the bedside (e.g. need to be performed in the operating room, need for general anesthesia, etc) or may need specialized surgical skills:
- Large abscesses which require extensive incision, debridement, or irrigation
- Abscesses in areas which require a general anesthetic to obtain proper exposure or have a high risk for complications (supralevator, ischiorectal, perirectal)
- Palmar space abscesses, or abscesses in the deep plantar spaces
- Abscesses in the nasolabial folds (may drain to sphenoid sinus, causing a septic phlebitis)
- Presence of a pulsatile mass at the site of infection, proximity to the vasculature and nervous structures, the presence of a foreign body.
- Abscesses due to animal/human bites
- Underlying bleeding disorders
- History of allergy to lidocaine, epinephrine if used for local anesthesia, or latex if using latex gloves.
Complications
- The most common complication of incision and drainage is pain.[5]
- Need for repeated procedure caused by items such as [5]:
- Failure to fully drain the abscess
- Inability to fully remove foreign bodies or bursa/capsule that might be causing the abscess.
- Inadequate antibiotic coverage
- Inadequately drained abscesses can lead to the extension of the infection into adjacent tissues and worsening of clinical status.
- Other potential complications include the development of fistulas, especially in the case of perirectal and periareolar abscesses.
- Neck abscesses that could potentially have developed from preexisting cystic lesions should be evaluated by an otolaryngologist due to the high potential for complications.
- Noncompliance in packing removal can lead to infectious complications, such as toxic shock syndrome.[13]
- Incisions may result in a poor cosmetic outcome for patients.[5]
HOW TO PERFORM INCISION AND DRAINAGE FOR SKIN AND SOFT TISSUE ABSCESSES
Assessment
- Prior to administering local anesthesia for wound care procedures, it is important that a comprehensive patient and abscess assessment be performed. See topic "How to Assess a Patient with Chronic Wounds"
Procedure: incision and drainage for skin and soft tissue abscesses
Tables 1 and 2 below illustrates steps for incision and drainage for skin and soft tissue abscesses.
Table 1. Procedure
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Steps
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Rationale/Tips
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1. Determine patient history of allergies or sensitivities which may contraindicate product use.
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2. Obtain patient’s consent per facility policy
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3. Ensure adequate assistance, supplies, and equipment: - Universal precaution materials (gown, gloves, protective eyewear)
- Sterile draping towels and sterile gloves
- Local anesthetic (1% or 2% lidocaine with or without epinephrine)
- 10-cc syringe and 25- to 30-gauge needle
- Skin prep material (chlorhexidine or iodine swabs)
- No. 11 or 15 blade and scalpel
- Curved hemostats
- Scissors
- Syringe with irrigation tip to fully irrigate area after collection drainage
- Saline or antimicrobial irrigation solution
- Packing ribbon gauze (optional)
- Dressing (4- × 4-inch gauze pads and tape)
- Swabs for wound culture (if desired)
|
- For details on when to use epinephrine, see topic "How to Administer Local Anesthesia for Wound Care Procedures"
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4. Position the patient comfortably and ensure affected area is exposed and visible.
| - While positioning, explain the procedure to the patient and let the patient know that they may feel a burning sensation at first, before the area becomes anesthetized
- Pain management might be necessary for larger abscesses
- Advise the patient about the potential for scarring prior to the procedure
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5. Open supplies onto separate surface or tray, in an area independent of patient or clinician movement.
| - Tools should never be placed on an unstable surface, such as the patient; this could potentially cause injury.
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6. Prep the surface of the abscess and the adjacent skin area with an antiseptic solution, which can either be povidone-iodine or chlorhexidine. Drape the abscess with sterile towels.
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| 7. Administer local anesthesia | - See topic "How to Administer Local Anesthesia for Wound Care Procedures"
- While positioning, explain the procedure to the patient and let the patient know that they may feel a burning sensation at first, before the area becomes anesthetized
- For smaller abscesses, local infiltration of lidocaine is used, while larger ones may require a field block technique. Note that lidocaine may be less effective in the acidic environment of an abscess
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8. Make a linear incision with a no. 11 or 15 blade into the abscess
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- The incision should be made parallel to skin tension lines in order to prevent scar tissue formation
- Ensure adequate incision size: ensure the incision is wide enough to enable sufficient drainage, as a narrow incision can lead to abscess recurrence.
- Be cautious during incision, as abscess contents may spray, particularly if anesthesia is injected into the abscess. Wear personal protective equipment to prevent self-contamination.
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9. Drain abscess
| - Facilitate the release of the abscess' purulent content by allowing it to drain naturally.
- Collect culture specimen if indicated. See topic "How to Collect a Wound Swab (Levine Technique) for Culture"
- Use curved hemostats to gently probe and disrupt any loculations within the abscess.
- Try to manually squeeze out additional purulent content from the abscess for thorough drainage
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10. Insert packing material into the abscess with hemostats or forceps (optional)
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- For abscesses with a diameter of 5 cm or less, it is advised against using wound packing. [13]
- This recommendation is based on evidence suggesting that packing does not significantly influence healing outcomes and may actually lead to increased pain.[12] Additionally, studies have not demonstrated that packing effectively lowers the risk of abscess recurrence.[12]
|
11. Dress the wound with sterile dressing and secure dressing
| For local wound care suggestions, see "Wound Prep and Dress Tool" |
Table 2. Post-procedure
| Steps | Rationale/Tips
|
1. Prescribe antibiotics at the discretion of the treating clinician.
| - The use of systemic antibiotics for skin and soft tissue abscesses after incision and drainage has been shown to result in an increased rate of clinical cure.[3]
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| 2. Instruct the patient when to return for dressing change and monitoring. | - It is recommended to schedule a follow-up appointment within 2 to 3 days post-procedure for the removal of any packing material that might have been used in the wound. After this, the wound should be allowed to heal naturally through the process of secondary intention.
|
| 3. Document procedure and send a culture if indicated | See section 'Documentation' below |
Documentation
Documentation should include [8]:
- Documentation of the pretreatment evaluation and any abnormal physical findings.
- Documentation of the procedure:
- Record the time out, indication for the procedure, the outcome, how the patient tolerated the procedure, medications (drug, dose, route, & time) given, complications, and the plan in the note, as well as any teaching and discharge instructions.
- Precise location of the lesion
- The type of lesion (e.g., abscess, paronychia, hidradenitis suppurativa, furuncle, carbuncle, lymphangitis, hematoma, cyst)
- A description of the procedure to include whether incision or puncture, amount and quality of drainage, probing and deloculation when performed, and whether wound was packed, drain inserted or left open.
CODING, COVERAGE, REIMBURSEMENT
Medicare Administrative Contractors and Local Coverage Determinations
Medicare coverage of provider and facility fees related to wound cultures is managed by Medicare Administrative Contractors (MAC), under Medicare Part A or Part B. Each jurisdiction may have its own specific local coverage determination and policies. See topic "Medicare Coverage Determinations for Wound Care".
CPT codes
Incision and drainage codes
- Examples of incision and drainage codes frequently performed in wound care are:
- 10061: Incision & drainage abscess complicated/multiple
- 10060: Incision & drainage abscess simple/single
- For updated codes and fee amounts, refer to topic "HCPCS/CPT Codes and Physician Fee Schedule Commonly Utilized in Wound Care and HBOT"
Ultrasound interpretation
- Ultrasounds interpretation is a separately billable service frequently used to diagnose and locate a cyst, hematoma, seroma or abscess. Permanent image retention and documented findings related to the reason the study was performed are necessary to capture ultrasound as a separately billable service.[8][14]
- CPT Code 76882 represents a limited evaluation of a joint or a focal evaluation of a structure(s) in an extremity other than a joint (e.g., soft-tissue mass, fluid collection, or nerve[s]
Coding Tips
- Use care choosing the correct CPT® codes. Some descriptors indicate incision or puncture, while others do not specify the type of approach for a specific location. Similarly, ICD-10-CM diagnosis codes linked to the procedure should accurately reflect the location and type of lesion drained. [8]
- If there is inflammation adjacent to a nail or ingrown nail and the only service provided is trimming the edge of the nail, the incision and drainage codes should not be used. Trimming the nail to prevent recurrence of paronychia is considered to be routine foot care, which has limited coverage.[4]
- Incision and drainage services are not payable for treatment of blisters unless there is superinfection with pus and abscess formation.[4]
- Providers performing permanent correction of recurring ingrown nail by nail resection (plate, bed, and nail matrix, partial or complete) or by wedge excision of the nail lip, should not bill incision and drainage services. Removal of lytic fragments of the nail plate to relieve symptoms of inflammation without infection of the soft tissues is a routine foot care procedure.[4]
