Written by Damian Baalmann, M.D. and reviewed by Dustin Leigh, M.D.
A 49 year-old, previously healthy female presents to your emergency department with chief complaint of a boil on her left thigh. Otherwise, the patient denies any fevers, chills, systemic symptoms. The patient first noted this boil 3 days ago and it has since grown in size and is painful to touch. Vitals reveal that she is normotensive, not tachycardic, afebrile and satting well on room air. Exam reveals 4-cm tender, fluctuant, erythematous nodule on the lateral aspect of the mid left thigh. No apparent overlying cellulitis or lymphadenopathy and the rest of the physical exam is within normal limits. Quick look with bedside ultrasound confirms your suspicion of a non-loculated, cutaneous, drainable abscess. Your nursing staff has kindly already brought lidocaine/epinephrine, a scalpel, 25-gaugle needle, syringe, normal saline, and for some reason, packing supplies to the bedside.
Abscesses are the most common dermatological conditions managed by emergency physicians.  Treatment of an abscess is drainage and may involve irrigation, primary versus secondary closure, and antibiotic treatment. The intricacies of the techniques (large incision vs small incision), irrigation, closure, and antibiotic treatment are generally case dependent and not supported with robust literature and will not be discussed in this post. The topic of this post is whether to pack or not to pack cutaneous abscesses. Historically, cutaneous abscesses have been packed sterilely with wicks to promote epithelial lining of the abscess cavity and to prevent entrapment of the bacteria in the abscess. Typically, the patient would then be instructed to return to the emergency department for repacking or sent home with packing materials to self-pack until the wound has healed.
It has been argued that there is no evidence-based science behind packing of cutaneous abscesses that have been incised and drained. Because of this lack of evidence, two randomized controlled trials have somewhat recently been performed.
In 2011, Schmitz et al surveyed 350 emergency medicine providers regarding abscesses and found that 91% of these providers still packed abscesses following I&D. 
Upon our review of the current literature we found insufficient evidence to support routine packing of subcutaneous abscess. While most studies have been small with few RTC’s there does not appear to be evidence of increased recurrence of abscesses when not packed. However, multiple studies do identify increased patient discomfort. There is probably no benefit to packing cutaneous abscesses as it does not appear to prevent reoccurrence of abscesses or decreasing further intervention at follow-up. There is probably harm with packing abscesses as may be an associated increase in pain post-procedure and at 48-hour follow-up. Bottom line: do not pack cutaneous abscesses.
You opt to not reach for the packing gauze on the table and send the patient out after I&D. After return instructions are given, she leaves with an understanding to return if worsening or not improving.
Want to know more about abscesses? Check out this great review article about “Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus” 
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