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.
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.
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!
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: