Overview

Boils, called furuncles (‘/Foo-roon-kools/’), are red, painful bumps filled with pus that form under the skin when bacteria infect hair follicles. It is often caused by Staphylococcus aureus. These infections are common and can affect anyone. Boils are red, tender lumps that quickly fill with pus as the infection continues. While they can appear anywhere on the body, they are most commonly found in areas prone to friction and sweating, such as the neck, face, armpits, thighs, and buttocks. Knowing the causes, symptoms and treatments of boils is necessary for quick recovery and prevention of these painful skin infections.¹

Recurrent boils, also known as furunculosis(‘/Foo-roon-koo-luh-sees/’), are painful, pus-filled infections of hair follicles that tend to recur over time. It often causes discomfort and concern for affected individuals. These skin abscesses, usually caused by bacterial infection, can be set off by several factors, including weak immune systems, underlying medical conditions, and poor hygiene. Recognising the causes and applying effective treatment plans are important for preventing recurrence and enhancing skin health. This article delves into the common causes of recurrent boils and explores both medical treatment and lifestyle changes aimed at reducing their occurrence and easing their effect on quality of life.²

Causes of recurrent boils

The causes of recurrent boils are as follows:³

Bacterial infections

• The most common cause of boils is infection by the bacterium Staphylococcus aureus
• Some individuals carry this bacterium on their skin or through nasal passages without showing symptoms, making them more prone to infections, when the skin barrier is breached

Poor hygiene

• Insufficient cleaning: Failure to maintain proper personal hygiene can allow bacteria to thrive on the skin, increasing the risk of infections
• Contaminated surfaces: Contact with contaminated surfaces, such as shared towels or clothing, can spread bacteria, leading to recurrent boils

Weak immune system

• Chronic conditions: Diseases like diabetes, HIV/AIDS, and other conditions that weaken the immune system can reduce the body's ability to fight off infections, leading to recurrent boils
• Medications: Long-term use of immunosuppressive drugs or corticosteroids can also impair the immune response, making recurrent infections more likely

Skin conditions

• Eczema and dermatitis are skin conditions that cause itching and inflammation. They damage the skin barrier, making it easier for bacteria to enter and cause infections
• Acne: Severe acne can provide entry points for bacteria, leading to the development of boils

Close contact and crowded living conditions

• Household transmission: Living in close quarters with others can spread bacteria through direct contact or shared items
• Community settings: Schools, hostels and military barracks are environments where recurrent boils are more common due to close physical nearness and shared spaces

Genetic predisposition

• Genes can make one vulnerable to Staphylococcus aureus infections, making some families more likely to get recurrent boils

Nutritional deficiencies

• Lack of essential nutrients can weaken the immune system and skin health, making it harder for the body to fend off bacterial infections

Hormonal changes

• Changes in hormones, such as during puberty or menstrual cycles, can affect skin integrity and immune function, leading to recurrent boils

Obesity

• Excess weight can create skin folds, which are prone to friction and sweating, providing an environment for bacterial growth

Medical devices and procedures

• Indwelling devices: The use of catheters or other medical devices that break the skin can introduce bacteria and lead to recurrent infections
• Surgical wounds: Post-surgical wounds or other skin trauma can serve as entryways for bacteria, increasing the risk of boils

Diagnosis of recurrent boils

Clinical evaluation

The diagnosis of recurrent boils begins with a thorough clinical evaluation, including:

Patient history:

• Frequency and duration: Document the frequency, duration, and pattern of the boils
• Location: Note if the boils are localised to specific areas or if they appear in multiple regions
• Associated symptoms: Ask about systemic symptoms such as fever, fatigue, or malaise
• Previous treatments: Review treatments used and their effectiveness, including antibiotics and any surgical interventions
• Personal and family medical history: Check for a history of diabetes, immunodeficiency, skin conditions, or similar issues in family members

Physical examination

• Check and palpate the affected areas to assess the number, size and stages of boils
• Look for signs of cellulitis or abscess formation
• Identify any underlying skin conditions like acne or dermatitis that may predispose to infections

Laboratory investigations

To identify the causative organism and any underlying conditions, the following laboratory tests are recommended:

• Microbiological tests:
  • Culture and Sensitivity: Obtain a sample of pus from the boil for bacterial culture and sensitivity testing. This identifies the causative bacteria (commonly Staphylococcus aureus) and determines the appropriate antibiotics
  • Blood Cultures: In cases of systemic involvement, blood cultures may be necessary
• Blood tests:
  • Complete Blood Count (CBC): Check for signs of infection or underlying conditions such as anaemia
  • Blood Glucose Levels: Test for diabetes mellitus, as high blood sugar levels can predispose individuals to recurrent infections
  • Immunological Tests: Assess for conditions like HIV, chronic granulomatous disease, or other immune deficiencies
• Additional tests:
  • Nasal Swabs: Screen for nasal carriage of Staphylococcus aureus, which can be a reservoir for recurrent infections
  • Skin Biopsy: In rare cases, a skin biopsy might be needed to rule out other dermatological conditions

Imaging studies

When deeper infections are suspected, imaging studies can be useful:

• Ultrasound:
  • Helps to differentiate between simple boils and abscesses
  • Can guide drainage procedures if needed
• MRI or CT Scan:
  • Used in severe cases to evaluate the extent of infection, especially if deeper structures like muscles or bones are involved

Differential diagnosis

Several conditions can mimic recurrent boils. These include:

• Hidradenitis Suppurativa: Chronic skin condition causing painful, inflamed lumps, often confused with boils
• Cysts: Sebaceous or epidermoid cysts can become infected and present similarly to boils
• Carbuncles: Clusters of boils that merge to form larger infected areas
• Pilonidal Disease: Chronic skin infection near the tailbone, often misdiagnosed as boils

Management strategies for recurrent boils

According to the American Academy of Dermatology, the following are immediate steps to treating recurrent boils:⁹

• Warm compresses:
  • Applying warm compresses to the affected area several times a day; can help with drainage and ease pain
• Incision and drainage (I&D):
  • For larger boils, a healthcare professional may need to perform I&D to reduce pressure and drain pus
• Antibiotic therapy:
  • Topical antibiotics: Mupirocin or fusidic acid can be applied directly to the affected parts
  • Systemic antibiotics: Oral antibiotics may be necessary for recurrent cases, with selection guided by culture and sensitivity results

Preventive strategies

Health hygiene

• Regular cleansing: Wash affected areas with antibacterial soap
• Hand hygiene: Regular handwashing and use of hand sanitisers help mitigate the spread of bacteria
• Laundering: Regular washing of towels, bedding, and clothing in hot water kills bacteria
• Decolonization:
  • Nasal Mupirocin: Applying mupirocin ointment to the nostrils twice daily for 5-7 days can reduce Staphylococcus aureus carriage²
  • Chlorhexidine baths: Daily bathing with chlorhexidine gluconate for 5-14 days can help eradicate skin carriage of the bacteria²

Addressing underlying conditions

• Diabetes management: Adequate blood sugar control can reduce the incidence of infections
• Weight management: Weight loss in obese patients can reduce skin friction and sweating, which predispose them to boils
• Immune support: Treating conditions that compromise the immune system can be beneficial

Lifestyle and behavioral modifications

• Diet and nutrition: A balanced diet rich in vitamins and minerals supports immune function and skin health
• Hydration: Adequate fluid intake is essential for overall skin health
• Stress management: Reducing stress through mindfulness, yoga, or other techniques can bolster immune function

Long-term monitoring and follow-up

• Regular check-ups: Periodic evaluations by a healthcare professional to monitor for new boils and manage any chronic conditions
• Patient education: It is important that you learn the signs and symptoms of recurrence and the necessity of early treatment

Advanced and adjunctive therapies

• Immunotherapy: In cases of chronic or severe recurrent boils immunotherapy may be considered
• Vaccination: Research is ongoing into vaccines against Staphylococcus aureus, which could offer future preventive options⁶

Herbal remedies for recurrent boils

Recurrent boils can be treated with various herbal remedies containing antibacterial, anti-inflammatory, and immune-boosting properties. Here are some effective options:¹⁰

• Turmeric: Turmeric can be taken orally (as a supplement or in food) or applied topically as a paste
• Neem: Applying a paste of neem leaves to the boil can help reduce infection and promote healing
• Tea tree oil: With its powerful antibacterial properties, tea tree oil can be applied directly to the boil. Reconstitute with a carrier oil to avoid skin irritation
• Garlic: Crush fresh garlic and apply the juice to a boil, or consume garlic cloves to boost immunity.
• Aloe vera: Aloe vera gel can soothe the skin and help reduce inflammation. Apply the gel onto the boil site(s)
• Echinacea: Echinacea can be taken as a tea or supplement to help the body fight infections and reduce the recurrence of boils

N.B: Always consult a healthcare provider before starting any herbal treatment, especially if you have underlying health conditions or are on other medications.

Special considerations

Recurrent boils in pediatric and immunocompromised patients are often due to weakened body defences, making it hard for the body to fight off infections. In children, frequent boils may indicate underlying issues like juvenile diabetes, skin conditions, or immune deficiencies.¹¹ Immunocompromised patients, such as those with HIV/AIDS, cancer, or immunosuppressive medications, are also at higher risk.

Effective management includes maintaining good hygiene, using antiseptic washes, and in some cases, antibiotic therapy. It's important to tackle any underlying health conditions and boost the immune system through proper nutrition and medical care. Regular monitoring and early treatment can help prevent complications and improve outcomes for those who are vulnerable in our population.¹¹

Summary

Recurrent boils are often caused by bacterial infection of hair follicles. It can be caused by factors like poor hygiene, compromised immunity, or conditions, like diabetes. Management includes good hygiene practices, use of topical antibiotics and addressing underlying health issues to prevent recurrence.