• Scenario: Boils and carbuncles: covers the management of boils and carbuncles, including recurrent and chronic cases.
• Scenario: Folliculitis: covers the management of staphylococcal folliculitis.
• Scenario: Acute paronychia: covers the initial management of acute paronychia, and when to refer people for incision and drainage.
• Scenario: Staphylococcal whitlow: covers the initial management of staphylococcal whitlow, and when to refer people for incision and drainage.
• Scenario: Staphylococcal carriage: covers the identification and management of staphylococcal carriage.

• A boil is a red, hot, tender, inflammatory nodule with walled-off purulent material, arising from a hair follicle. Boils can exude pus and necrotic material.
• A carbuncle is caused by infection of a group of adjoining hair follicles which develop into large, swollen, tender masses with multiple points draining pus. There may be inflammation in surrounding and underlying connective tissue.

• Size and position of the lesion.
• Presence of pus or fluctuance (wave-like feeling on palpating skin overlying a fluid-filled cavity with nonrigid walls).
• Symptoms suggesting systemic spread of infection.
• Whether a swab is required.

In depth

• Swabs are not routinely required for initial management.
• Swabs are indicated if the lesion is getting worse over 48 hours despite antibiotic treatment, or there is no response to empirical antibiotic treatment within 5–7 days.

In depth

• 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). Clinical judgement should be used, 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.

In depth

• 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.
• Consider admission if the person is unwell, or the infection is in an area where complications can be serious (e.g. the face). Clinical judgement should be used, 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.

In depth

• Oral flucloxacillin is recommended for empirical treatment.
• Oral erythromycin (or clarithromycin if erythromycin is not tolerated) is an alternative for people with penicillin allergy.

In depth

• A 7-day course of empirical antibiotic treatment is recommended.

In depth

• 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 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).

In depth

• For more information on the assessment and management of staphylococcal carriage, see Scenario: Staphylococcal carriage.

• Folliculitis is superficial infection of the hair follicles which develop into small inflammatory papules or pustules.

• Size and position of the lesion.
• Presence of pus or fluctuance (wave-like feeling on palpating skin overlying a fluid-filled cavity with nonrigid walls).
• Symptoms suggesting systemic spread of infection.
• Whether a swab is required.

In depth

• Swabs are not routinely required for initial management.
• Swabs are indicated if the lesion is getting worse over 48 hours despite antibiotic treatment, or there is no response to empirical antibiotic treatment within 5–7 days.

In depth

• Advise people to avoid aggravating factors (e.g. tight clothing or occlusive dressings or plasters, and, if shaving, to shave in the direction of hair growth).
• 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.

In depth

• Oral flucloxacillin is recommended for empirical treatment.
• Oral erythromycin (or clarithromycin if erythromycin is not tolerated) is an alternative for people with penicillin allergy.

In depth

• A 7-day course of empirical antibiotic treatment is recommended.

In depth

• 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.

In depth

• For more information on the assessment and management of staphylococcal carriage, see Scenario: Staphylococcal carriage.

• Paronychia is infection bordering the nail which causes painful swelling and possibly a visible collection of pus.

• Size and position of the lesion.
• Presence of pus or fluctuance (wave-like feeling on palpating skin overlying a fluid-filled cavity with nonrigid walls).
• Symptoms suggesting systemic spread of infection.
• Whether a swab is required.

In depth

• Swabs are not routinely required for initial management.
• Swabs are indicated if the lesion is getting worse over 48 hours despite antibiotic treatment, or there is no response to empirical antibiotic treatment within 5–7 days.

In depth

• 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.

In depth

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

In depth

• Oral flucloxacillin is recommended for empirical treatment.
• Oral erythromycin (or clarithromycin if erythromycin is not tolerated) is an alternative for people with penicillin allergy.

In depth

• A 7-day course of empirical antibiotic treatment is recommended.

In depth

• 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:
• If the person is able to take penicillin, change the antibiotic to co-amoxiclav.
• 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 frequently wet hands).
• Swab for mycological culture, and if positive for candida, treat with a topical imidazole or consider oral treatment if the person is immunocompromised.
• If candidal paronychia is associated with nail infection, see the CKS topic on Fungal nail infection.

In depth

• Staphylococcal whitlow is an abscess of the fleshy area of the palmar aspect of the fingertip.

• Size and position of the lesion.
• Presence of pus or fluctuance (wave-like feeling on palpating skin overlying a fluid-filled cavity with nonrigid walls).
• Symptoms suggesting systemic spread of infection.
• Whether a swab is required.

In depth

• Swabs are not routinely required for initial management.
• Swabs are indicated if the lesion is getting worse over 48 hours despite antibiotic treatment, or there is no response to empirical antibiotic treatment within 5–7 days.

In depth

• 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 (e.g. osteomyelitis, skin necrosis, sinus tract formation, septic joint, tenosynovitis, compartment syndrome) are suspected.
• Offer analgesia (paracetamol or ibuprofen) if needed.

In depth

• 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 (e.g. osteomyelitis, skin necrosis, sinus tract formation, septic joint, tenosynovitis, compartment syndrome) are suspected.
• Offer analgesia (paracetamol or ibuprofen) if needed.

In depth

• Oral flucloxacillin is recommended for empirical treatment.
• Oral erythromycin (or clarithromycin if erythromycin is not tolerated) is an alternative for people with penicillin allergy.

In depth

• A 7-day course of empirical antibiotic treatment is recommended.

In depth

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

In depth

• 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.

In depth

• In primary care, nasal swabs should be taken.

In depth

• 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 to:
• Use an antiseptic preparation to reduce staphylococcal skin colonization. Washing the skin (preferably including hair), and daily bathing is recommended in an antiseptic solution of chlorhexidine or triclosan in a detergent vehicle.
• 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.

In depth

• A solution of chlorhexidine or triclosan in a detergent vehicle is generally suitable:
• Hibiscrub^® and Hydrex^® Surgical Scrub contain chlorhexidine.
• Aquasept^® skin cleanser and Ster-Zac bath concentrate^® contain triclosan.
• For dry or inflamed skin, or application to the face, use an antiseptic emollient:
• The Dermol^® range contains chlorhexidine and benzalkonium chloride.
• Emulsiderm^® bath additive contains benzalkonium chloride.