A Better Way to Drain Abscesses: The Berlin Technique

One of the consequences of the heroin epidemic we all are experiencing is a marked increase in the number of skin abscesses presenting to the jail medical clinics.  Jails have always had to deal with skin abscesses.  In fact, the single most popular JailMedicine post has been the Photographic Tutorial on Abscess I&D (found here).  But since the heroin epidemic, the number of skin abscess we see has exploded.  It is not unusual nowadays to lance an abscess every day!

The reason for this big increase in skin infections, of course, is that heroin users tend to share needles to shoot up, and these dirty needles leave behind the bugs that cause abscesses.  And since shooting up causes the abscesses, they tend to be found where addicts commonly shoot up–like the inner elbow, the forearm and even overlying the jugular veins of the neck.

Fortunately, just in time for this onslaught of abscesses, my good friend Neelie Berlin PA taught me a new method of lancing simple abscesses that is quicker and easier—yet just as effective—as the method I had been using for my entire career. I’m going to call this new method of draining abscesses “The Berlin Method.”

Who says you can’t teach an old Doc new tricks?  I have wholeheartedly gone over to the Berlin procedure.  It is THE method I use now to drain simple abscesses.

Today’s JailMedicine post is a pictographic tutorial on how to do this new easier method of lancing simple abscesses.

The instrument that makes the Berlin Method possible is the 4mm punch biopsy tool, shown here:

The 4mm punch biopsy tool replaces the scalpel in the older technique.

You may have some of these 4 mm biopsy tools already stocked, since we use them to do, well, skin biopsies.  But if you haven’t, they are easy to order from your favorite medical supply company.  They cost around $2.50 apiece, which is close to the price of a scalpel.

Here is a typical nasty abscess that we commonly see in our clinics:


The step-by-step procedure to drain this abscess using the Berlin technique goes like this:







Clean the skin.  There is no need in most cases to use betadine or other formal skin prep procedures.  Lancing any kind of abscess is a clean procedure rather than a sterile procedure.  I usually clean the skin with alcohol–but soap and water would work as well.  There is also no need for sterile drapes or sterile gloves, since they will immediately be contaminated with pus, anyway.  I usually get clean towels and 4X4s ready to catch the pus when it oozes out.

Anesthetize with lidocaine or bupivacaine (Marcaine).  Everyone seems to stock lidocaine, but bupivacaine is a superior product. Bupivacaine lasts four times longer than lidocaine.  It is a little more expensive, but worth it, in my opinion.  I typically also use bupivacaine with epinephrine, since it will last a little longer.  The site of the anesthesia should be where the abscess is “pointing,” if possible.  Notice also that you need to anesthetize far less skin in the Berlin technique compared to the older method.  You only need a wheal slightly larger than the 4mm hole the biopsy tool will make.

Punch a hole in the abscess with the 4mm biopsy tool.  This is pretty simply.  You place the cutting edge of the punch biopsy against the skin and twist and press until you have reached the hub.  Then remove the tool.  The pus will instantly pour out, so be ready!

Drain the abscess.  This requires some mild squeezing and pressure.  You do not have to be too aggressive, though.

Irrigate the wound, if necessary.  I will do this if the pus is so thick that I am afraid some is still trapped in the abscess cavity.  If the pus is really runny, there may be no need to irrigate.

There is no need for any type of packing material.  Remember that packing material had one function and one function only:  It prevented the wound edges from resealing and the abscess from reforming.  The 4mm punch biopsy tool leaves a perfectly circular hole that will not seal over.

Apply a dressing.  The wound will continue to weep for a day or so. Patients should be encouraged to wash the wound in clean running water, like a shower.

Cultures are unnecessary in most patients.  I would consider a wound culture only immunocompromised patients or who are otherwise complicated.

Similarly, there is no need for antibiotics in most cases since draining the abscess will cure the vast majority.  I would consider an antibiotic if the patient has cellulitis or, again, is a complicated case.

I have found that using the punch biopsy tool has several advantages over my old technique of using a scalpel and packing material.

It’s much faster.  Including the time required to set everything up, the old method takes 10-15 minutes.  I can drain a simple abscess using the Berlin technique easily in 5 minutes.

It’s less expensive.  The punch biopsy tool costs around $2.50 apiece–which is about the same as the cost of a scalpel.  The main cost saving is that I no longer open a suture kit using this new technique, since I no longer need the instruments in it.  That is a savings of about $15.00 per procedure.  Plus I don’t have to open a bottle of packing material!

I have lost count of the number of abscesses I have now drained using a punch biopsy tool.  In my informal series, I have had no complications, no problems and no treatment failures. Here is another case:

What technique do you use to drain simple abscesses?  Have you had success with an alternative technique?  Please comment!

23 thoughts on “A Better Way to Drain Abscesses: The Berlin Technique

  1. What about looking for multiple chambers, especially for “iceberg” versions, when using the Berlin method? As you wrote earlier, it is only with examination one knows the extent and number of chambers. One can think it is small, but likeep an iceberg discover more exists below the surface.

    • Hi Bertram,

      I had the same thought myself when I first began to use the Berlin technique. However, I have only used out with small/moderate sized abscesses on the extremities–and so far, I have and no problems. Were I to encounter a larger abscess in a more problematic area, I would probably go back to fully opening and exploring.

  2. Hi Jeffrey, Thanks for sharing this- very interesting. I am a surgeon working in Norway. We are working on a webside calle http://www.woundsafrica.com ( not online yet) which will provide information on wound care for off the grid clinics in Africa ( free of charge). We would like to ask if we can use this article on using a biopsy punch to drain abscesses on that webiste. We would obviously give you full credits for the pictures and text.

    Best regards,

    • Thank you Bodo! You certainly have permission to reprint or otherwise use any photographs or writings from JailMedicine with the appropriate credit.


  3. Dr Keller-

    Thank you for your article. I believe this technique should become standard operating procedure in emergency rooms across the country. At the very least ,”The Berlin Method,” should be considered for every abcsess case. Thank you again.

    • Thank you Nickolas! The Berlin technique is simply the quickest and easiest way to drain an uncomplicated abscess–period.

  4. The Berlin Method would a great alternative technique for Street Medicine! I would love to adopt this method. Thank you for sharing and I will credit JailMedicine as I share with others on our team.

  5. Wonder if Ms. Berlin was a military PA (or medic) thats where it was first seen by me. The other trick was 18 guage needle to lift the skin off the proximal nail (no cut) to drain a parynicia.

  6. Hi. I’m in America with limited access to health care due to our political corruption. I had been draining my frequent abscesses from HS with a number 11 blade hobby knife. My family doctor didn’t have a problem with it, as long as I sterilized the skin as best I could before using a new blade. Well, I cut through to the floor for the first time in fifteen years. Hurt like a mfer and I was so worried about spreading infection. I decided there must be a better tool and googled “skin punch abscess.” I’m glad to see the punch can be used. It will be expensive for me at $2.50 each but I wouldn’t dare try to reuse one. I hope they come in smaller than 4mm size. Maybe a very large needle would be better.

    • That is a very bad idea. As the article states the 4mm hole allows you not to need to pack it. I.e (insert a gauze wick) any smaller and the chance of a scab. or even a blood clot covering/blocking the hole and you just end up with the same issue again. I know 4mm seems large but it’s really not, it actually very small. I guarantee if your abscess is big enough. or you got it from iv use, whatever caused it…it won’t hurt nearly as bad as it did to cause it, or as much as it did before you started draining it. Keep it very clean. And needle to drain is a horrible idea for the fact if you stick it into the pocket and not knowing through a vein you have introduced the bacteria into your blood.now you’re introducing a whole new level of infections. Including endocarditis( infection of the blood that spreads to the heart )

      • Angel,
        In my facility, I have never seen anyone use the Berlin Technique. The Seton I &D Technique is commonly used. Dr. Todd Wilcox submitted a post about the Seton procedure in December 2021, If you are interested.

        • Hello,

          Is it me or does Jail Medicine seem dead for new topics beyond discussion over the Berlin method.

          I remember there being something interesting weekly, but now …

          Thank you.

  7. Thank you for your article. I’m going to pass this on to the ER doctors next time I have an abscess but I take issue with something you wrote. The year I began using Guilliani made it legal to purchase syringes in NYC & needle exchanges had become widely available. I’ve never shared needles in my life because I’ve never had to nor do I know any addict my age whose had to. They are so widely available I sometimes trip over them in the street (sealed ones). My frequent abscesses have to do with the bad habits I’ve ritualized in my addiction, such as not cleaning the injection site before I inject or reusing my cottons too often. Addiction breeds a great deal of chaos in your life sometimes what you’re seeing as Drs is the result of that chaos. Also, I bring this up to highlight that there isn’t enough reseach done on this population & too often Drs make assumptions that dont apply. Perhaps it would be a good idea for Drs to do a rotation in addiction medicine as well the other specialties. Considering how large & varied this population is becoming it might come in handy….

    • He is a doctor for people in jail, so sharing needles probably is common. They won’t be giving out free needles as they aren’t allowed drugs in prison

      • I doubt he’s seeing abscess that are a result from people using inside jails. Maybe prisons have more of those cases but it’s very rare to have many people using needles in county jail. He’s probably treating new inmates that arrived with abscesses. Most of the time,from my experience, jail MD’s could care less until the abscess is on the verge of popping anyway. The “MD” in my local county jail is actually a veterinarian. That might not be the case now as it’s been a while since I’ve used the lovely facilities. But bodies are bodies for the most part I guess. Lol, the guy was OBSESSED with finding Syphilis. I guess he was a philosophy fan?

        • Bob! I wholeheartedly agree! This doctor seems like a good guy that cares (I’ve been witness to some pretty awful staff on jails, drs included) but that was way off base. I am sober now but in my past 8 years of using and hanging around with tons of addicts, I only met ONE person who refused others needles. I sadly got a ton of abscesses around the last couple years of my use. I thought they were from missing my shots when I muscled them because it usually coincided with that but I also usually didn’t prep my site with alcohol pads. Speaking that way (falsely, at least for a large part of addicts nowadays) about addicts only increases the stigma and makes things harder for current and former addicts. Loved the article. Just wanted to add this.

          • I don’t understand why ANYONE would inject anything without steralizing the site first. You can literally get a 400 pack of alcohol wipes for less than $4 at Walmart. Much less sharing needles. Ick.

  8. hi there,
    thanks so much for this clear and wonderful tutorial . i plan to adapt this to my practice.

    just a few questions

    1) why 4mm bore? would 2 or 3 be too small for thicker pus
    2) if you’re not suturing closed how long does it take to heal/close and what do you advise in terms of managing this?

    thanks again

  9. Hello!
    I appreciate the advice. i am an addict from upstate NY, and i have a giant abcess on my hip from IMing stimulants. i plan to lance/ drain tomorrow but wont have access to injectable numbing agents. is there a topical skin numbing solution? how about ice? i understand heat is valuable in coaxing pus out of the wound… but can i use ice to numb the spot before i slice? thanks! and again i cannot be talked out of trying so please refrain from focusing on that in reply.

    • Lidocaine 4% cream is available otc and works fairly well. Just use a small amount and I usually poke the spot with a lancet (I’m diabetic, so I have a ton of lancets) and when I can’t feel anything (not even pressure) you know your good to cut. Clean with alcohol before you cut, the lidocaine will have done it’s job enough by that point that wiping it with a alcohol wipe isn’t going to cause any issues

  10. Just had this technique performed on my wrist this past week. I was by myself and don’t look when things are happening, but after seeing the shape of the hole and how fast this technique was, i now know this was the Berlin Technique. I was given antibiotics because my swelling had spread very far and was significantly infected. The berlin technique leaves the cavity open for a reason, however this does make it for a little longer healing.

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