Ichthammol Ointment (Drawing Salve)

Ichthammol is one of the oldest topical medicines still in use. It is made by distilling sulfur-rich oil shale, sulfonating the oil, and neutralizing it with ammonia, which gives a dark, viscous, tar-smelling liquid that pharmacists have been mixing into ointments since the 1880s. In the United States it survives mainly as the drawing salve sold in small jars for boils and splinters.

No ichthammol product is FDA-approved. The over-the-counter 10 to 20% salves are marketed without FDA review, and a compounded ichthammol ointment is a 503A preparation that is not FDA-approved either. Bayview compounds it when a prescriber orders a specific strength and base, most often 10%, 12%, or 20% in white petrolatum or a lanolin-free base, for an individual patient. A valid prescription is required. Bayview compounds this as part of our dermatology compounding line.

How does it work?

The folklore says a drawing salve pulls infection, splinters, or toxins out through the skin. The laboratory evidence says something narrower. In a 2022 study on three-dimensional human skin models, ammonium bituminosulfonate ointments loosened the outer skin in a concentration-dependent way, reduced two of the proteins that hold the epidermis together, and made the skin more permeable (Fink et al., 2022). That softening is the plausible reason a boil under an ichthammol dressing sometimes comes to a head and drains on its own, and why a splinter can become easier to lift; nothing is pulled, the skin over it is loosened. Separately, sulfonated shale oil kills bacteria in the test tube: in a 2020 study using modern susceptibility methods it was active against Staphylococcus aureus, including methicillin-resistant strains, against streptococci, and against the acne bacterium Cutibacterium acnes, with much weaker activity against Gram-negative bacteria (Idelevich and Becker, 2020). How much of that activity reaches bacteria inside a boil through intact skin has not been measured. Older reviews also describe mild anti-inflammatory and antifungal effects (Boyd, 2010).

What is it used for?

For more than a century ichthammol has been applied to furuncles (boils), folliculitis, and the inflamed skin fold beside an ingrown toenail, and, in lower strengths, to eczema, seborrheic dermatitis, psoriasis, and leg ulcers (Boyd, 2010). Prescribers still order it for a small early boil that has not formed a pocket of pus, for the tender skin around an ingrown nail, for a splinter or insect bite, and occasionally for hidradenitis suppurativa. A 2020 paper reported a small case series of 10% ichthammol in hidradenitis together with a systematic review of ichthammol's published use in dermatology, and the literature it found is old, small, and largely uncontrolled (Fisher and Ziv, 2020). That is the honest state of the evidence: long experience, some laboratory support, and very few trials. Your prescriber decides whether it fits your situation.

When a boil needs a clinician, not a salve

An abscess is a walled-off pocket of pus, and the definitive treatment is incision and drainage by a clinician; antibiotics alone are not sufficient once a pocket has formed, and a salve is not either (StatPearls, Incision and Drainage). Ichthammol belongs, if anywhere, at the small, early, tender-lump stage. Do not use it as a substitute for care if the lesion is larger than about 2 cm, very painful, spreading, surrounded by widening redness or red streaks, on the face or near the spine, or if you have a fever, feel unwell, have diabetes, or have a weakened immune system. Those are reasons to be seen the same day.

Ichthammol is not black salve

The name overlaps and the color is similar, which causes real harm. The product sold as black salve is a corrosive paste made from bloodroot (sanguinarine) and zinc chloride that destroys whatever tissue it touches; it has been promoted as a home treatment for skin cancer, moles, and warts, the published clinical reports describe disfigurement and delayed cancer diagnosis, and no trial supports it (Lim, 2018). The FDA lists black salve among illegally sold cancer treatments (FDA, Illegally Sold Cancer Treatments). Ichthammol contains no bloodroot and no zinc chloride, does not burn tissue, and is not a treatment for any skin growth. If you have a mole, a sore that will not heal, or a lump you are worried about, that is a visit to a clinician, not a salve of any kind.

How is it used?

Follow the directions on your label exactly. Wash and dry the area, apply a thin layer of ointment to the lesion and a small margin of skin around it, and cover it with a dry gauze dressing; ichthammol is dark, smells of tar, and stains fabric permanently, so the dressing protects your clothes as much as the skin. Change it once or twice a day as directed, washing your hands afterward. A typical course is a few days. If a boil has not improved after 3 to 5 days, or gets worse at any point, stop and see a clinician. Keep it out of the eyes, mouth, and nose and off mucous membranes, and do not use it on a deep or open wound or a burn.

Side effects & safety

Ichthammol is generally well tolerated on intact skin. The usual effects are mild stinging, redness, or itching at the site, softening or wrinkling of the skin under the dressing, and a temporary brown stain. The problem to watch for is allergic contact dermatitis: ichthammol is a recognized, if weak, sensitizer, and a rash that gets redder, itchier, or blistered, or spreads beyond where the ointment was applied, means stop and tell your prescriber. The smell and the staining are not side effects, but they are the reason most people stop using it.

Who should not use it?

Avoid ichthammol if you are allergic to it, to sulfonated shale oil, to coal tar or other tar products, or to any ingredient in the base, and do not use it on the eyes, mouth, nose, genitals, or a deep or open wound. Tell your prescriber if you are pregnant or breastfeeding, if you have diabetes or a weakened immune system (a boil in those settings needs a clinician's eye), and if you have ever reacted to a tar shampoo or ointment. Use in children calls for a pediatric prescriber's direction.

How should it be stored?

Store as directed on your label, at room temperature away from heat, flame, and light, tightly closed, and keep it out of the reach of children and pets. Do not use it after the beyond-use date, and dispose of unused medication as directed.

Why is this compounded?

There is no FDA-approved ichthammol to dispense. The over-the-counter drawing salves are sold at 10 to 20% in whatever base the maker chooses, marketed without FDA review, and a prescriber who wants a particular strength, a lanolin-free or preservative-free base, a paste, a larger jar, or ichthammol combined with another ingredient has no manufactured option. As a 503A compounding pharmacy, Bayview prepares each order in small batches under USP standards, pursuant to a prescription for an individual patient. We do not supply ichthammol as clinic or office stock, that is the role of a 503B outsourcing facility, which Bayview is not. Compounded preparations are not FDA-approved. Related preparations include Ciclopirox Cream, Gel & Nail Lacquer, Cantharidin for Warts & Molluscum, and Acne Treatments. The full list is in our compounded medications catalog.