Assess:

• Size and position of the lesion.
• Presence of pus or fluctuance.
• Symptoms suggesting systemic spread of infection.
• Whether a swab is required.
• Whether it is a recurrent problem.

• Fluctuance is a wave-like feeling on palpating skin overlying a fluid-filled cavity with nonrigid walls (e.g. a cavity containing pus) [Pugh, 2000].
• Swabs are not always necessary, but are useful in certain situations. For more information, see Need for a swab.
• Identification and treatment of staphylococcal carriage can be beneficial for people with recurrent lesions. For more information, see Managing staphylococcal carriage.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Laube, 2004; Ladhani and Garbash, 2005; Iwatsuki et al, 2006].

• Swabs are not routinely required for the initial management of boils, carbuncles, folliculitis, acute paronychia, and staphylococcal whitlow.
• Swabs are indicated if:
• The lesion is getting worse over 48 hours despite antibiotic treatment.
• There is no response to empirical antibiotic treatment within 5–7 days.
• For people with recurrent boils, carbuncles, or folliculitis:
• Identification and treatment of staphylococcal carriage can be beneficial.
• For more information, see Managing staphylococcal carriage.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Laube, 2004; Ladhani and Garbash, 2005; Iwatsuki et al, 2006].
• There is only value in swabbing discharging lesions, or those that have undergone incision and drainage. Swabbing inflamed skin is not helpful [McNulty, Personal Communication, 2006].

• The management of boils and carbuncles will depend on whether the lesion is fluctuant or non-fluctuant.

• Advise the person to apply moist heat three to four times a day.
• Offer antibiotics if:
• There is also fever or cellulitis.
• The lesion is large (e.g. carbuncle) or on the face.
• There are other comorbidities (e.g. diabetes).
• Offer analgesia (paracetamol or ibuprofen) if needed.
• Consider admission if the person is unwell, or the infection is in an area where complications can be serious (e.g. the face).

• The decision of whether to admit the person will depend on clinical judgement, taking into account the rapidity and degree of spread, and whether or not the person (or carer) is able to follow instructions reliably regarding monitoring of complications.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Lee et al, 2003; Ladhani and Garbash, 2005; Stevens et al, 2005].
• The aim of applying moist heat is to relieve discomfort, help localize the infection, and promote drainage.
• It is uncertain whether antibiotics should be used to treat all boils, as CKS could find no trial evidence. Expert opinion suggests that antibiotics are not always necessary, but should be particularly considered if the lesion is large (e.g. carbuncles) or there is associated fever or surrounding cellulitis, there are other comorbidities (e.g. diabetes), or the site means complications are more likely (e.g. cavernous sinus thrombosis can result from boils on the face). For more information, see Complications.
• Most cases can be treated in primary care provided the person is closely monitored for signs of systemic upset.

• Incise and drain (this can be done locally if the skills to do this exist within the practice, or alternatively refer).
• Offer antibiotics if:
• There is also fever or cellulitis.
• The lesion is large (e.g. carbuncle) or on the face.
• There are other comorbidities (e.g. diabetes).
• Offer analgesia (paracetamol or ibuprofen) if needed.
• Advise people to cover the lesion with a sterile dressing once it has drained.
• Consider admission if the person is unwell, or the infection is in an area where complications can be serious (e.g. the face).

• The decision of whether to admit the person will depend on clinical judgement, taking into account the rapidity and degree of spread, and whether or not the person (or carer) is able to follow instructions reliably regarding monitoring of possible complications.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Lee et al, 2003; Stevens et al, 2005].
• Covering the lesion with a sterile dressing once drainage has occurred (either spontaneously or surgically) helps to prevent autoinoculation.
• It is uncertain whether antibiotics should be used to treat boils that have been incised and drained, as CKS could find no trial evidence. Expert opinion suggests that antibiotics are not always necessary, but should be particularly considered if the lesion is large (e.g. carbuncles), if there is associated fever or cellulitis, there are other comorbidities (e.g. diabetes), or the site means complications are more likely (e.g. cavernous sinus thrombosis can result from boils on the face). For more information, see Complications.
• Most cases can be treated in primary care provided the person is closely monitored for signs of systemic upset.

• Swab the lesion to confirm the causative organism and antibiotic sensitivities.
• If staphylococcal infection is confirmed, check for carriage of Staphylococcus aureus.
• Exclude other underlying causes, for example:
• Systemic disorders (e.g. diabetes, immunocompromised) — consider checking full blood count and blood glucose.
• Skin disease (e.g. scabies, pediculosis, eczema).
• Localized predisposing factors (e.g. industrial exposure to chemicals, oils, poor hygiene).

• For further information on confirming and managing carriage of Staphylococcus aureus, see Managing staphylococcal carriage.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Lee et al, 2003; Hay and Adriaans, 2004].

• Advise people to avoid aggravating factors for folliculitis.
• Daily washing with an antiseptic product may help to prevent or control mild cases.
• For localized folliculitis, topical fusidic acid can be used.
• If folliculitis is more extensive or severe, empirical treatment with oral antibiotics may be needed.

• Advice should include avoidance of tight clothing, occlusive dressings and adhesive plaster, and (if shaving) to shave in the direction of hair growth.

• Folliculitis is often mild and self-limiting if the predisposing factors are removed.
• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Laube, 2004; Sladden and Johnston, 2005; McNulty, Personal Communication, 2006].

• Swab the lesion to confirm the causative organism and antibiotic sensitivities.
• Consider whether the cause could be non-infective.
• Consider whether the diagnosis is correct.
• If staphylococcal infection is confirmed, check for carriage of Staphylococcus aureus.

• Non-infective causes of folliculitis include trauma, occlusion, idiopathic, vitamin A or C deficiency, and actinic superficial folliculitis [Luelmo-Aguilar and Santandreu, 2004; Satter and Cyr, 2006].
• For more information on how to check for staphylococcal carriage, see Managing staphylococcal carriage.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus), although other organisms can cause folliculitis. Expert opinion from the medical literature has also been considered [Lee et al, 2003; Hay and Adriaans, 2004; Luelmo-Aguilar and Santandreu, 2004; Satter and Cyr, 2006].

• Management of acute paronychia will depend on whether fluctuance is present or absent.

• Advise the person to use warm soaks three to four times a day.
• Treat empirically with oral antibiotics.
• Offer analgesia (paracetamol or ibuprofen) if needed.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Clark, 2003; Lee et al, 2007].
• The aim of using warm soaks is to relieve discomfort, localise the infection, and promote drainage.

• Incise and drain (this can be done locally if the skills to do this exist within the practice, or alternatively refer).
• Offer antibiotics if:
• There is also fever or cellulitis.
• There are other comorbidities (e.g. diabetes).
• Offer analgesia (paracetamol or ibuprofen) if needed.

• This is pragmatic advice based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature. There is no evidence that oral antibiotics are any better or worse than incision and drainage for treating acute paronychia [Shaw and Body, 2005; Lee et al, 2007].
• It is uncertain whether antibiotics should be used to treat all fluctuant paronychiae that have been incised and drained, as CKS could find no trial evidence. Expert opinion suggests that antibiotics are not always necessary following incision and drainage, but should be particularly considered if there is associated fever or cellulitis, or there are other comorbidities (e.g. diabetes).

• If there is no response to antibiotics within 5-7 days or the paronychia is getting worse over 48 hours despite antibiotic treatment:
• Take a swab of any pus or discharge to confirm the infecting organism (choice of antibiotic should be guided by sensitivities).
• Incise and drain if the paronychia is fluctuant and this has not already been done (this can be done locally if the skills to do this exist within the practice, or alternatively refer).
• If there is no pus to swab, and incision and drainage of the paronychia is not appropriate:
• Change the antibiotic to co-amoxiclav if the person is able to take penicillin.
• If the person is allergic to penicillin, continue erythromycin (or clarithromycin if the person is unable to tolerate erythromycin) and add metronidazole.
• If there is no response to the change in antibiotic, consider candidal infection (especially if person has the risk factor of frequently wet hands).
• Swab for mycological culture, and if positive for candida, treat with topical imidazole.
• If candidal paronychia is associated with nail infection, see the CKS topic on Fungal nail infection.
• If the person is immunocompromised, consider oral antifungal treatment.

• Incision and drainage can be done locally if the skills to do this exist within the practice, or alternatively refer.
• There is only value in swabbing discharging lesions, or those that have undergone incision and drainage. Swabbing inflamed skin is not helpful.

• This is pragmatic advice based on the most likely causative organisms (Staphylococcus aureus, Streptococcus sp, or anaerobes) and expert opinion [Scott, 2002; McNulty, Personal Communication, 2007].
• Anaerobes may be responsible for paronychial infection caused by nail biting or finger sucking [Lee et al, 2007].
• If there is proximal red streaking or lymphadenopathy, consider the possibility of a mixed infection with streptococcus [Lee et al, 2003].
• There is no evidence that oral antibiotics are any better or worse than incision and drainage for treating acute paronychia [Shaw and Body, 2005].

• Management of staphylococcal whitlow will depend on whether the lesion is fluctuant or non-fluctuant.

• Advise the person to:
• Elevate the finger.
• Use warm soaks three to four times a day.
• In addition, treat empirically with oral antibiotics.
• Referral for IV antibiotics should be considered if oral antibiotics fail, the person is unwell, or proximal lymphangitis or cellulitis is present.
• Urgently discuss management with a specialist if complications are suspected.
• Offer analgesia (paracetamol or ibuprofen) if needed.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Clark, 2003; Lee et al, 2003].
• The aim of elevation of the finger and the use of warm soaks is to relieve discomfort, localise the infection, and promote drainage.
• There is the potential for serious complications (e.g. osteomyelitis) to develop as a result of staphylococcal whitlow [Lee et al, 2003; Rontal and Bailey, 2005; Vaughn, 2006].

• Refer for incision and drainage:
• Only attempt in primary care if skilled in incising and draining staphylococcal whitlows.
• In addition, treat empirically with oral antibiotics.
• Referral for IV antibiotics should be considered if oral antibiotics fail, the person is unwell, or proximal lymphangitis or cellulitis is present.
• Urgently discuss management with a specialist if complications are suspected.
• Offer analgesia (paracetamol or ibuprofen) if needed.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Clark, 2003; Lee et al, 2003].
• There is the potential for serious complications (e.g. osteomyelitis) to develop as a result of staphylococcal whitlow [Lee et al, 2003; Rontal and Bailey, 2005; Vaughn, 2006].
• Serious complications can also occur as a result of inappropriate drainage techniques for staphylococcal whitlow. Incision and drainage can be done locally, but only if the skills to do this exist within the practice.

• Urgently discuss further management with a specialist, for example general-, plastic-, or orthopaedic surgeon, depending on local policy.

• This is pragmatic advice. There is the potential for serious complications (e.g. osteomyelitis) to develop, and serious complications can also occur as a result of inappropriate drainage techniques for staphylococcal whitlow [Lee et al, 2003; Rontal and Bailey, 2005; Vaughn, 2006]. Therefore, if there is no response to treatment, urgent discussion with a specialist is recommended.

• Consider taking swabs for carriage of Staphylococcus aureus in people with recurrent or chronic boils, carbuncles, or folliculitis.
• Swabbing for carriage of Staphylococcus aureus in recurrent cases of paronychia or staphylococcal whitlow can be considered, but if the person requires referral, this may be done in secondary care as part of their further management.

• For more information on which sites to swab, see Managing staphylococcal carriage.

• These recommendations are pragmatic advice, based on the most likely causative organism (Staphylococcus aureus) and expert opinion from the medical literature [Lee et al, 2003; Ladhani and Garbash, 2005].
• Taking swabs for Staphylococcus aureus will help to exclude autoinoculation as the cause.
• Many studies have shown that people who are colonised with S. aureus are at higher risk of developing staphylococcal infections [Ladhani and Garbash, 2005].
• S. aureus is a persistent member of the microbial flora in 10–20% of the population, and approximately 30–50% of healthy adults harbour S. aureus at some site at any given time [Lee et al, 2003].
• S. aureus does not generally cause infection in people who are healthy, unless local barriers are broken [Ladhani and Garbash, 2005].

• In primary care, nasal swabs should be taken.

• This recommendation is based on the likely sites of staphylococcal carriage (other sites mentioned in the literature include throat, umbilicus, axillae, and perineum) and the practicalities of primary care.

• Eliminate nasal carriage: apply mupirocin nasal ointment three times a day for 5 days.
• Following treatment, three clear swabs over a 3 week period are required to confirm eradication.
• If mupirocin is not effective (e.g. in mupirocin-resistant isolates), consider applying Naseptin^® cream (chlorhexidine plus neomycin) four times a day for 10 days.
• If both mupirocin and Naseptin^® are ineffective, seek expert advice regarding the need for throat-carriage screening and the need for systemic antibiotics.
• Eliminate non-nasal carriage: oral treatment with antibiotics may be necessary, especially if there is throat carriage. The choice of antibiotic should be guided by sensitivities. Advice may be sought from the local infection control team.
• In addition, advise the person to:
• Use an antiseptic preparation to reduce staphylococcal skin colonization. Washing the skin (preferably including hair), and daily bathing in an antiseptic solution of chlorhexidine or triclosan in a detergent vehicle, is recommended. For further information on which antiseptic preparation to use, see Which antiseptic product to prescribe.
• Wash sheets and underwear regularly on a hot wash cycle (above 55°C). The clothes should be turned inside out and the machine not overloaded so that the water can circulate.
• Thoroughly clean the bedroom at the same time as treatment is started.
• Use his or her own towel and flannel, and rinse the flannel in hot water before use.
• Dressings should be changed frequently if purulent discharge collects.
• If boils, carbuncles, or folliculitis persist after screening and treating the person, seek advice from the local infection control team.

• These recommendations follow advice from the Health Protection Agency regarding eliminating staphylococcal carriage [Cookson, Personal Communication, 2007].
• One small study found that mupirocin eradicated more cases of nasal carriage than Naseptin cream [Leigh and Joy, 1993].

• Consider identifying and treating potential sources of infection in the family and close contacts.
• Actual infections are a more likely source of infection than asymptomatic carriage, but consider screening household members if they are willing to co-operate with an eradication strategy. However, this may be difficult to organize in primary care.