Beyond the Knife: A Contemporary Review of Subcutaneous Abscesses

Subcutaneous abscesses are among the most common soft-tissue infections encountered in acute surgical and emergency practice. While incision and drainage (I&D) remains the cornerstone of treatment, the best post-I&D strategy remains debated. Key questions include whether adjunct antibiotics improve cure rates or prevent recurrence, whether packing the cavity provides any advantage, and whether modern alternatives such as primary closure, drains, or irrigation offer superior outcomes. These issues are particularly relevant to perianal abscesses, where the risk of developing a fistula-in-ano is substantial, and to general cutaneous abscesses, where pain, delayed healing, and recurrence are frequent concerns. Recent randomized trials and contemporary guidelines have begun to clarify these controversies, helping clinicians move beyond traditional dogma toward evidence-based, patient-centered care. Landmark evidence now shows that, for uncomplicated cutaneous abscesses, adding a short course of MRSA-active antibiotics to I&D improves short-term cure and reduces new lesions. For perianal abscesses, the goal shifts to preventing fistula-in-ano: here the trials conflict, pooled estimates hint at a modest benefit from antibiotics, and clinical judgment still matters. Perhaps the clearest evidence-based shift is against routine packing, as it offers no outcome advantage and clearly increases pain. Large randomized data support abandoning it in favor of simple dressings or selective drains. Modern, patient-centered management now emphasizes thorough drainage, selective antibiotics, and avoidance of routine packing; use simple dressings or short-term drains when needed, and arrange reliable follow-up. That combination reduces pain and resource use without sacrificing safety.