Treatment of Scalp Skin Infections

Initial Diagnostic Approach

Bacterial infections present with purulent drainage, crusting, erythema, warmth, and tenderness, and require systemic antibiotics targeting Gram-positive organisms 1, 2
Abscesses present as fluctuant, localized collections requiring drainage, and may require antibiotics if systemic signs are present or if the patient is immunocompromised 1, 2
Culture specimens should be taken before initiating therapy when possible to guide antibiotic selection and identify resistance patterns 1, 2

For localized bacterial infections without systemic signs, first-line therapy is oral antibiotics targeting Gram-positive organisms, particularly beta-hemolytic Streptococcus and Staphylococcus aureus 1
Consider MRSA coverage if the patient is at risk, such as prior MRSA infection, IV drug use, failure of initial therapy, or high local MRSA prevalence 1, 3
For moderate to severe infections with systemic signs, empiric broad-spectrum IV therapy with vancomycin plus piperacillin-tazobactam, a carbapenem, or ceftriaxone plus metronidazole is recommended 3

For gonococcal scalp abscesses in newborns, treatment with ceftriaxone 25-50 mg/kg/day IV or IM daily for 7 days is recommended, with extension to 10-14 days if meningitis is documented 4, 5, 6, 7
For scalp abscesses in IV drug users, higher MRSA risk necessitates empiric MRSA coverage, and consideration of polymicrobial infection including anaerobes 3

Incision and drainage is the primary and essential treatment for scalp abscesses, with antibiotics added only if systemic signs are present or if the patient is immunocompromised 1, 2, 3
Multiple counter-incisions are preferred over single long incisions to prevent step-off deformities and promote healing 2

For immunocompromised patients with suspected or confirmed HSV or VZV scalp infection, high-dose IV acyclovir is the treatment of choice, with oral antivirals used for mild cases or to complete therapy after IV treatment 8, 9

Never rely on topical antibiotics alone for bacterial scalp infections, as systemic therapy is required 4, 5, 6, 7
Never prescribe antibiotics for simple abscesses, as drainage is the definitive treatment 1, 2
Never miss MRSA coverage in high-risk patients, such as IV drug users or those with prior MRSA infection 3
Never forget to culture before starting antibiotics when feasible 1, 2