Primary closure for I&D of cutaneous abscesses?

In the recent issue of Acad Emerg Med, Singer et al did a randomised controlled trial of primary versus secondary closure (healing by secondary intention) of skin abscesses.

• Singer AJ, Taira BR, Chale S, Bhat R, Kennedy D, Schmitz G, Zehtabchi S. Primary versus secondary closure of cutaneous abscesses in the emergency department: A randomized controlled trial. Academic Emergency Medicine 2013, Jan;20(1):27-32.

Of note, as mentioned in the opening paragraphs of this article, this is not a new concept. There are quite a few studies which described primary closure after I&D leading to faster healing than secondary closure, and are just as safe. The caveat is, the majority of these studies are done in the OT by surgeons, under GA, and involve mainly the anogenital region.

What this latest study show, is that primary closure of garden variety skin abscesses seen in an ED, is non-inferior to secondary closure. The healing rate and treatment failure rate as defined by the authors were similar. Of note, these were small abscesses, patients with significant cellulitis (>5cm) were excluded, as well as immunocompromised patients or DM patients. Also, I&D done under procedural sedation were excluded.

The limitations described by the authors were;
- selection bias (big, angry looking abscesses were excluded).
- small study – not sufficiently powered to detect differences in primary outcome.
- small abscesses thus only small incisions were performed. If large abscesses with longer incisions were made, the difference may be significant.
- limited followup of 7 days.

Take home:
Primary closure of I&D wounds may not be as bad as you think. There is certainly a role for this, especially in larger abscesses or abscesses in areas where cosmetics is of concern. Patient selection or preference may help to select successful outcomes when primary closure is performed. The authors also note an interesting point made in an earlier study: packing may not be necessary after all in wounds left to close secondarily; less painful and heals just as well.

• O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscess is painful and probably unnecessary. Acad Emerg Med. 2009; 16:470–3.

However, it is worthy to note that in larger abscesses, there is also the loop incision and drainage technique, first described in this pediatric study.

• Tsoraides SS, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK. Incision and loop drainage: A minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg 2010, Mar;45(3):606-9.

Anecdotal reports suggest its efficacy in adult patients as well. So there you have it, three dogma changing possibly practice changing points in therapy of skin abscesses in the ED.

1. Primary closure works just as well, possibly better than healing by secondary intention.
2. Wound packing is probably unnecessary.
3. Loop incision and drainage is a good option for large abscesses.

Finally, a youtube video of the loop I&D technique; enjoy!