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Boils: What are boils and how to treat them

Skin Conditions, General | March 8, 2016 | Author: The Super Pharmacist

Skin conditions

Boils: What are boils and how to treat them

The word 'boil' is a popular term for a type of lesion that often appears in the form of a reddened, raised and firm lump on the skin. They tend to develop in areas where skin and other tissues 'fold' or are otherwise in a position to overlap and/or interact closely.

These may include regions such as:

  • Armpits
  • Buttocks
  • Eyelids
  • Face (e.g. around the nose)
  • Neck
  • Shoulders
  • Anogenital region

Boils: What are boils and how to treat themBoils most commonly arise in a follicle (hair root) and/or oil gland found in these areas. This condition is also known as furunculosis, based on the alternative term for this type of lesion ('furuncle').

A furuncle is a single boil, whereas a tight cluster of boils, often caused by the development of boils in additional follicles or glands in the immediate vicinity of an original lesion, is termed a carbuncle.

How They Develop

The development of boils is strongly associated with methicillin-resistant Staphylococcus aureus (MRSA) infection. More specifically, boils are thought to be caused by strains (subtypes defined by genetic variation) of MRSA that can express a toxin called the Panton-Valentine leukocidin (or Panton-Valentine virulence factor). This molecule, coded for by the lukS-lukF- gene, is associated with skin infections and also with severe pneumonia.

MRSA is commonly linked to hospital-acquired conditions; however, widespread outbreaks are also likely to occur in the wider community due to infections passed from person to person. Locations that may be affected by this may include:

  • Family homes
  • Urban or suburban areas
  • Other types of residences such as shared dormitories, where the risk of such infections is influenced by sharing towels, washing facilities, etc.
  • Sports and/or athletic clubs (or school sporting facilities) in which equipment and bathing facilities are shared regularly

MRSA is present in the nasal cavities of those affected (as are the non-virulent strains of S. aureus present in normal healthy people) which facilitates its spread through general person-to-person contact. It is also thought to be responsible for an estimated 60% of cases of recurrent boils. The incidence (and healthcare burden) of this condition appears to be on the increase. In England, boils and abscesses severe enough to require hospitalisation were reported to have tripled in the space of 15 years. MRSA-related furunculosis can spread to a relatively large proportion of a community once established; a recent outbreak in a German village of 144 residents resulted in primary infection of 42 of these, only six of which were isolated cases (i.e. not in shared homes).

Treatment and Prevention of Boils

Cases of boils tend to be recurrent, due to persistent MRSA infections that have a reduced susceptibility to antibiotics.

These bacteria may be eradicated, and their re-establishment prevented, by certain preventative measures.

This may also be known as MRSA decolonisation or disinfection protocols.

 

The risk of skin infections, including boils, will also be avoided by employing these measures, which may include:

  • The application of intranasal ointment containing the antibiotic mupirocin, typically repeated several times daily. Using an alcohol-based hand sanitizer immediately after doing so is also recommended.
  • Daily washing of hair and skin with a solution containing octenidin
  • Gargling with 0.1% chlorhexidine solution several times a day, as MRSA colonies may also be present in the mouth or throat
  • The disinfection of personal items (e.g. glasses or jewellery) daily
  • Cleaning surfaces such as the bathtub or shower with an alcohol-based antibacterial cleanser
  • The daily changing of bedclothes, towels, underwear, and clothing; and washing these at a temperature of 60°C or more.
  • Maintaining and improving hand hygiene
  • Avoiding or reducing contact with other people in the immediate area.
  • The disinfection of equipment, protective clothing, etc. which may be shared by people who are infected or are at risk of infection

These procedures may be carried out for a short period of time, typically five days or more. They may significantly eradicate MRSA, achieving a full removal of colonies in up to 99% of cases. However, recurring infections may occur in some cases. In these situations, the disinfection procedures may be repeated until the bacterial colonies - and thus the skin infections - are fully erased. The success of decolonisation may be directly affected by non-adherence to the protocols as above.

Other treatments for boils

Longer courses of mupirocin ointment or chlorhexidine-based products.

This may be accompanied by the systemic administration of clindamycin, another of the few antibiotics associated with treatment of MRSA-related skin infections.

Low-dose X-ray therapy is another treatment historically linked to improvements in cases of furunculosis. The exposure of a lesion to this radiation has been reported to destroy the bacterial colonies, and also stimulate immune mechanisms that combat MRSA infection.

Lancing, or the piercing of the lesion with a needle which may be heated. Lancing is in fact ineffective and inadvisable, as it may simply lead to the spread of infection to other areas (or people). In addition, lancing may lead to a more invasive and extensive MRSA infection. This may result in more severe symptoms such as fever and the development of abcesses (lesions in other tissues).

Drawing ointment. Drawing ointment, also known as drawing salve or black drawing salve, is a product linked to the treatment of skin injuries such as small splinters.

This ointment is derived from a type of stone rich in bitumen (shale) which contains the fossilised remains of fish. It is also known as icthyol or icthammol. This oil-like substance is regarded as a popular treatment choice for skin damage or infection, despite its strong and unpleasant smell (due at least in part to the high concentrations of sulphuric acid used in its production). It is linked in some clinical literature to positive effects on inflammatory, bacterial and fungal conditions.

The use of drawing ointment is a traditional measure in dermatology and otology, often in combination with another classic treatment, glycerol. Icthammol has been shown to be significantly effective in comparison with this substance in the inhibition of S. aureus colonies. Despite these reports, there is no clinical evidence of any effect of icthammol-containing products in cases of boils. Icthammol and/or glycerol are often recommended for similar conditions such as otitis externa, or the inflammation of the ear and/or ear canal.

A clinical trial randomised 82 patients with this condition to receive a pack containing either steroids and antibiotics or icthammol and glycerol. The group in the first group had significantly less pain after two follow-up consultations, and significantly less swelling after four consultations compared to the second group.

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References:

Wiese-Posselt M, Heuck D, Draeger A, et al. Successful termination of a furunculosis outbreak due to lukS-lukF-positive, methicillin-susceptible Staphylococcus aureus in a German village by stringent decolonization, 2002-2005. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2007;44(11):e88-95.

Calabrese EJ. X-Ray treatment of carbuncles and furuncles (boils): a historical assessment. Human & experimental toxicology. 2013;32(8):817-827.

Demos M, McLeod MP, Nouri K. Recurrent furunculosis: a review of the literature. The British journal of dermatology. 2012;167(4):725-732.

Shallcross LJ, Hayward AC, Johnson AM, Petersen I. Evidence for increasing severity of community-onset boils and abscesses in UK General Practice. Epidemiology and infection. 2014:1-4.

Mody L, Kauffman CA, McNeil SA, Galecki AT, Bradley SF. Mupirocin-Based Decolonization of Staphylococcus aureus Carriers in Residents of 2 Long-Term Care Facilities: A Randomized, Double-Blind, Placebo-Controlled Trial. Clinical Infectious Diseases. 2003;37(11):1467-1474.

Davido B, Dinh A, Salomon J, et al. Recurrent furunculosis: Efficacy of the CMC regimen--skin disinfection (chlorhexidine), local nasal antibiotic (mupirocin), and systemic antibiotic (clindamycin). Scandinavian journal of infectious diseases. 2013;45(11):837-841.

Engelhard EA, Spanjaard L, Stijnis CK. [Treatment of recurrent furunculosis]. Nederlands tijdschrift voor geneeskunde. 2013;157(5):A5548.

Medows M, Sharma A. Lancing of a boil leading to severe invasive methicillin-sensitive Staphylococcus aureus infection in an adolescent. BMJ case reports. 2013;2013.

Bernhardt MS. Better living through chemistry. JAMA Dermatology. 2013;149(9):1016-1016.

Gayko G, Cholcha W, Kietzmann M. [Anti-inflammatory, antibacterial and antimycotic effects of dark sulfonated shale oil (ichthammol)]. Berliner und Munchener tierarztliche Wochenschrift. 2000;113(10):368-373.

Nilssen E, Wormald PJ, Oliver S. Glycerol and ichthammol: medicinal solution or mythical potion? The Journal of laryngology and otology. 1996;110(4):319-321.

Shrestha BL, Shrestha I, Amatya RC, Dhakal A. Effective treatment of acute otitis externa: a comparison of steroid antibiotic versus 10% ichthammol glycerine pack. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India. 2010;62(4):350-353.

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