In this Part 3 of our 3-part podcast series on management of lacerations Dr. Haley Cochrane joins Anton and Justin to explore laceration aftercare and the evidence for keeping wounds dry or wet, wound dressings, topical antibiotics, prophylactic oral antibiotics, Vitamin E oil, aloe vera cream and UV protection with regards to cosmetic outcomes and infection rates. What may be the most important aspect of aftercare is educating the patient what to expect as the laceration heals and when they should seek medical attention…

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Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Anton Helman February, 2023

Cite this podcast as: Helman, A. Morgenstern, J. Cochrane, H. Laceration Aftercare – Dressings, Antibiotics, Improving Cosmesis, Preventing Infection. Emergency Medicine Cases. February, 2023. https://emergencymedicinecases.com/laceration-aftercare. Accessed April 23, 2024

Laceration aftercare question 1: Is it best to keep the wound dry or let it get wet?

  • Two small RCTs from the 1980’s showed no difference in infection rates when comparing keeping wounds dry vs wet.
  • A 2006 unblinded RCT of 870 family practice patients after simple skin excision randomized to 48hrs dry vs 12hrs dry followed by regular cleaning with soap and water showed no difference in infection rate.

Bottom line: the literature does not give us a clear answer to whether wounds should be kept dry or not.

Commentary: common sense would dictate that removing the dressing regularly to check for signs of infection and cleaning with soap and water is preferred over leaving a dressing on without checking it for signs of infection or cleaning the wound.

Laceration aftercare question 2: Do wound dressings help with laceration healing or prevent infection?

  • There are no ED-based studies looking at laceration wound dressings.
  • A Cochrane review of dressings after surgery for prevention of infection concluded that there is no good evidence that one dressing is better than another and based 2 low quality RCTs comparing dressings to no dressings, that there was no difference in infection rates.
  • Another Cochrane review based on 3 studies comparing early vs late removal of dressings from clean or contaminated surgical wounds found no difference in infection rates.

Bottom line: there is no good evidence to guide us as to whether dressings are of benefit or not for lacerations.

Commentary: common sense would dictate that using a dressing for the first few hours to prevent clothes getting blood on them is reasonable, that for patients working in environments where wound contamination is likely, that keep the wound covered during work is reasonable, and that for patients who live in dry climates, that petroleum jelly (petrolatum) applied to the wound is reasonable to prevent skin cracking/bleeding. For wounds under high tension in physically active patients, a splint-type dressing is a consideration as well.

Laceration aftercare question 3: Do topical antibiotics help prevent infection?

A 1995 double-blind RCT of 465 patients in a single center military hospital were randomized to receive bacitracin, neomycin/bacitracin/polymyxin B, silver sulfadiazine or placebo. Simple stitch abscesses that did not require any management were found in 6%, 5%, 12% and 18% respectively. There was one patient with an allergic reaction.

Bottom line: there is evidence to suggest that topical antibiotics decrease the risk of insignificant simple stitch abscesses that do not require any change in management or have any significant impact on patient outcomes.

Laceration aftercare question 4: Which lacerations require prophylactic oral antibiotics?

  • A 2001 Cochrane Review of 8 RCTs found that prophylactic antibiotics do not seem to decrease rates of infection from dog or cat bites, however in human bites there was and decrease rate of infection and in the subgroup of patients with mammalian bites to the hand there was a significant decrease in infection rates with an NNT =4.
  • A 1994 meta-analysis of 8 RCTs found that prophylactic antibiotics reduced the rate of infection with relative risk reduction of 0.56. However, the definition of infection seems to have included minor erythematous immune response.

Bottom line: there is some evidence to suggest that prophylactic antibiotics after human bites and after animal bites to the hand decreases infection rates.

Commentary: It seems reasonable to reserve antibiotic prophylaxis for these two indications and for deep lacerations, dirty lacerations that enter a large joint, immunocompromised patients, and perhaps mammalian bites to the face.

Laceration aftercare question 5: Are there any other medications or treatments that improve cosmesis or decrease infection rates?

Aloe vera: no ED studies, 1 post-skin biopsy studied found no benefit

Honey: Cochrane review of both chronic and acute wound with 3 RCTs looking at acute wounds found no benefit

Vitamin E: no ED studies, 3 blinded RCTS after surgery show no benefit

UV light protection: no human studies; some animal models suggest UV light can worsen scars

Bottom line: There are no other medications or treatments that have been shown to improve cosmesis or decrease infection rates for lacerations

Laceration aftercare instructions

What may be the most important aspect of laceration aftercare is educating the patient what to expect as the laceration heals and when they should seek medical attention. As we outlined in Part 1 and Part 2 of this series, what we do in the ED for lacerations has little impact on outcomes. The evidence is weak for any of the classic dogma that we have been taught about managing lacerations.

  • Consider a dressing for the first few hours to prevent clothes from getting blood-stained and continue using a dressing if exposed to high contamination risk environments, while removing the dressing daily to check for signs of infection and wash with soap and water.
  • Petroleum jelly daily application for a week is reasonable in dry environments
  • Topical antibiotics are not necessary as they seem to only prevent small insignificant  infections, and there is a risk of allergic reaction
  • Oral antibiotics should be reserved for patients with human bites, dog/cat bites to the hand, grossly contaminated deep wounds, dirty lacerations into large joints and immunocompromised patients
  • Avoid water that has high contamination risk (lakes, hot-tubs, public swimming pools) until the skin is healed
  • Seek medical attention if redness is spreading/streaking from the laceration, increasing pus, increasing pain

Journal Jam 21 Laceration Management – Does Timing of Closure, Irrigation, Gloves Type, Eversion Matter?

Journal Jam 22 Laceration Repair – Glue vs Strips vs Staples vs Sutures

References

  1. Morgenstern, J. Laceration evidence part 7: Aftercare instructions, First10EM, December 26, 2022. Available at:
    https://doi.org/10.51684/FIRS.128678
  2. Heal C, Buettner P, Raasch B, Browning S, Graham D, Bidgood R, Campbell M, Cruikshank R. Can sutures get wet? Prospective randomised controlled trial of wound management in general practice. BMJ. 2006 May 6;332(7549):1053-6.
  3. Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T, Macefield R, Blencowe N, Milne TK, Reeves BC, Blazeby J. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev. 2016 Dec 20;12(12):CD003091.
  4. Toon CD, Lusuku C, Ramamoorthy R, Davidson BR, Gurusamy KS. Early versus delayed dressing removal after primary closure of clean and clean-contaminated surgical wounds. Cochrane Database Syst Rev. 2015 Sep 3;2015(9):CD010259.
  5. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995 Jul;13(4):396-400.
  6. Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. The Cochrane database of systematic reviews. 2001.
  7. Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Annals of emergency medicine. 23(3):535-40.
  8. Dat AD, Poon F, Pham KB, Doust J. Aloe vera for treating acute and chronic wounds. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD008762.
  9. Eshghi F, Hosseinimehr SJ, Rahmani N, Khademloo M, Norozi MS, Hojati O. Effects of Aloe vera cream on posthemorrhoidectomy pain and wound healing: results of a randomized, blind, placebo-control study. J Altern Complement Med. 2010 Jun;16(6):647-50.
  10. Jull AB, Cullum N, Dumville JC, Westby MJ, Deshpande S, Walker N. Honey as a topical treatment for wounds. Cochrane Database Syst Rev. 2015 Mar 6;(3):CD005083.
  11. Tanaydin V, Conings J, Malyar M, van der Hulst R, van der Lei B. The Role of Topical Vitamin E in Scar Management: A Systematic Review. Aesthet Surg J. 2016 Sep;36(8):959-65.
  12. Toon CD, Lusuku C, Ramamoorthy R, Davidson BR, Gurusamy KS. Early versus delayed dressing removal after primary closure of clean and clean-contaminated surgical wounds. Cochrane Database Syst Rev. 2015 Sep 3;2015(9):CD010259.