Folliculitis profunda (boil/carbuncle)

Staphylodermia follicularis et perifollicularis profunda, Staphylodermia follicularis profunda necroticans, Staphylodermia follicularis profunda.

A boil is an often painful, abscessing inflammation of the follicles and perifollicular with scarring healing. Several confluent boils combine to form a carbuncle.

Infection with Staphylococcus aureus, especially in patients with immune suppression. Mostly due to autoinoculation.

• Furuncle:
  • Size-progressive pustules which eventually form a nodule with surrounding oedema. Fluctuation occurs in the course of the disease. Often crusts are also visible
  • A pain on pressure is typical
  • When splitting, pus empties
  • Partially red. General condition with febrile temperature, fatigue and exhaustion

• Carbuncles:
  • Confluent boils

• Clinic
• BB (e.g. leukaemic disease), ESR, temp, DM exclusion if necessary
• Nasal vestibule swab

Predilection sites include the external auditory canal (extremely painful), upper lip, nose, neck, buttocks and inner thighs.

Locoregional lymphadenitis, thrombosis (sinus vein thrombosis) and thrombophlebitis in nasal and auricular furuncles, orbitaphlegmone, menigitides in centrofacial localisation.

• Inpatient admission, if: General symptoms (fever), facial boils, immunosuppression
• Ensure the site is immobilised and elevated
• In case of lip furuncle, do not talk
• Soft diet
• No manipulation by patients
• Wash bedclothes and nightclothes regularly
• Trim fingernails

Topical therapy

• Before opening the skin lesion:
  • Ammonium bituminosulfonate 10,20,50% ointment
  • (Face, neck and in the genitoanal region only 20%)

• After opening the skin lesion:
  • Tamponade (soaked gauze) with iodine-povidone solution

• Moist antimicrobial poultices:
  • Polihexanide Concentration, Lsg.
  • Tricolosan skin wash emulsion

NO RINSE WITH octenidine dihydrochloride - CREATION OF NEcrosis IS POSSIBLE!

Systemic therapy

• For example: Penicillinase-safe penicillins (flucloxacillin) 500mg p.o
  • Add. take 500mg 3-4x per day approx. ½ to 1h before meals
  • KI: liver dysfunction, mononucleosis, lymphocytic leukaemias, lactation
  • Intravenous therapy is useful for facial boils!

• In case of penicillin allergy:
  • Erythromycin
  • Administration: 4x dd. 500 mg. p.o. (adults), maximum dose: 4 g/d (adult), 40-100 mg/kg bw/day (5-12 yrs)
  • CI: Hypersensitivity to ingredients, liver dysfunction, concurrent therapy with ergotamine or dihydroergotamine or hepatotoxic drugs, dose adjustment recommended in renal or hepatic insufficiency
  • CAVE:
    • If there is evidence of hepatotoxicity or ototoxicity, immediate discontinuation is indicated
    • Exacerbation of myasthenia gravis
    • Immune deficiency (HIV, DM and leukaemia) should be ruled out in the case of recent furuncles
    • For staphylococcal colonisation of the nasal vestibule, use of e.g.:

• Mupirocin nasal ointment 2x a day for 5-10 days
  • KI: breastfeeding, hypersensitivity to ingredients
  • Radiation therapy with e.g.: red light and short-wave light can lead to faster maturation of the follicle

1. Arnaiz-Garcia AM, Arnaiz-Garcia ME, Arnaiz J. [Management of furuncle, furunculosis and anthrax]. Med Clin (Barc) 2015;144:376-8.
2. Dallaire-Dufresne S, Tanaka KH, Trudel MV, Lafaille A, Charette SJ. Virulence, genomic features, and plasticity of Aeromonas salmonicida subsp. salmonicida, the causative agent of fish furunculosis. Vet Microbiol 2014;169:1-7.
3. Rashtak S, Gamble GL, Gibson LE, Pittelkow MR. From furuncle to axillary web syndrome: shedding light on histopathology and pathogenesis. Dermatology 2012;224:110-4.
4. Demos M, McLeod MP, Nouri K. Recurrent furunculosis: a review of the literature. Br J Dermatol 2012;167:725-32.
5. Eiland G, Ridley D. Dermatological problems in the athlete. J Orthop Sports Phys Ther 1996;23:388-402.
6. Jorda V. Diseases of hairy skin. Curr Probl Dermatol 1984;12:185-223.