Version July 2025
INTRODUCTION —
A wound is a disruption of the normal structure and function of the skin and soft tissue architecture [1]. An acute wound demonstrates normal physiology, and healing is anticipated to progress through the stages (figure 1) of wound healing [2,3].
To ensure proper healing through the expected stages, the wound base should be well vascularized, free of devitalized tissue, clear of infectious burdens, and have appropriate hydration. Wound dressings can help facilitate this process if they eliminate dead space, prevent bacterial overgrowth, and ensure proper fluid balance. They must also demonstrate cost efficiency and be manageable for the patient and other caregivers or nursing staff.
Open wounds with progressive healing, as evidenced by granulation tissue and epithelialization, may heal completely on their own or might undergo delayed primary closure or coverage by a skin graft or flap, or skin substitute. All wounds are expected to be colonized with microbes; however, this does not imply that all wounds are infected [4,5].
The basic principles and available options for the management of acute wounds are reviewed. The management of chronic wounds (eg, diabetic foot ulcers, pressure-induced skin or soft tissue injury, ischemic ulceration, gangrene, atypical, malignancy-associated wounds) is reviewed separately. (See "Overview of treatment of chronic wounds".)
WOUND DEFINITIONS AND CLASSIFICATION
Acute wounds — Acute wounds occur suddenly and usually have an easily identifiable mechanism of injury leading to disruption of skin integrity. Regardless of etiology, wound healing normally progresses at a sustained, measurable rate through the stages of healing as expected. A typical example is a closed surgical wound, which can be expected to effectively heal with remodeling within four to six weeks (figure 2). (See "Basic principles of wound healing", section on 'Wound healing'.)
The precise timeline for complete epithelialization varies depending on numerous factors, including comorbidities (eg, diabetes, autoimmune disease, peripheral artery disease), increased body mass index, anatomic location, and medications. An acute wound that is associated with physiologic impairments that slow or prevent wound healing may progress to become a chronic wound, although there is no specific time threshold that clearly differentiates an acute from a chronic wound [6]. (See "Risk factors for impaired wound healing and wound complications".)
Surgical versus nonsurgical wounds
●Surgical wounds – Surgical wounds are a controlled form of acute wound intentionally created in the operating room (eg, surgical incision, surgical drain site). This also includes incisions created to decompress an abscess, fasciotomy incisions, or other forms of debridement. An open surgical wound may also be due to disruption of a suture line, which can be intentional because of a concern for surgical site infection or spontaneous related to suture breakage.
Surgical wounds are classified into four categories according to the degree of bacterial load or contamination. The surgical wound class (ie, clean, clean-contaminated, contaminated, or dirty) (table 1) is documented for each procedure. Most clean and clean-contaminated wounds are closed primarily at the completion of surgery, while contaminated and dirty wounds are generally left open and require wound care.
●Nonsurgical wounds – A nonsurgical wound is caused by another mechanism. Acute traumatic skin disruption can result from blunt or penetrating mechanisms with an array of wound sizes, shapes, depths, and locations. Thermal, electrical, chemical injury or another mechanism may also be involved. Because of these varying mechanisms, individualized evaluation, management, and care of the wound are required.
Some relatively clean wounding mechanisms may allow for washout and primary closure. (See "Minor wound evaluation and preparation for closure" and "Skin laceration repair with sutures".)
Superficial versus deep wounds — Analogous to the classification of burn wounds (figure 3), acute wounds can be classified as superficial or deep. Superficial wounds do not penetrate beyond the dermis. Deep wounds involve the subcutaneous tissues and may involve muscle and bone.
INITIAL CARE —
Wounds that have devitalized tissue, contamination, or residual foreign material (eg, sutures, glass) benefit from cleaning and debridement prior to further wound management.
Acute traumatic wounds may have irregular devitalized edges or foreign material within the wound, and surgical wounds that have dehisced may have an infected exudate, gastrointestinal leakage, or necrotic muscle or fascia. These substances impede the body's attempt to heal by stimulating the production of abnormal metalloproteases and consuming the local biologic resources necessary for healing.
Irrigation — Irrigation is important for cleansing the wound, thereby decreasing the bacterial load and removing loose material, and should be a part of routine wound management [1,7-9].
●Type of irrigation and additives – There are no high-quality data to support the use of any particular additive to the irrigant, nor any particular additive over another. The act of irrigation and the volume of irrigant probably provide the primary positive benefits. Warm, isotonic (normal) saline is typically used; however, systematic reviews have found no significant differences in rates of infection for tap water compared with saline for wound cleansing [10,11]. The addition of dilute iodine or other antiseptic solutions (eg, chlorhexidine, hydrogen peroxide, sodium hypochlorite, antibiotics) is generally not necessary. Such additives have minimal action against bacteria, and some, but not all, may impede wound healing [12-14].
●Low versus higher irrigation pressure – Low-pressure irrigation (eg, <15 pounds per square inch) can be performed in any setting using a standard syringe or bulb syringe, whereas high-pressure irrigation (eg, pulsed lavage) is typically performed in the operative setting using a commercial device.
Low-pressure irrigation is usually adequate to remove material from the surface of most wounds. Although higher-pressure irrigators may lead to relatively minor local tissue damage and increased tissue edema, there are no specific data available to suggest a specific cutoff pressure above which tissue is damaged or impaired rather than improved.
For highly contaminated or dirty wounds, the benefits of reducing bacterial load may outweigh the risk of speculative adjacent tissue damage associated with the use of higher irrigating pressures. Even at higher pressure levels, which can also debride tissue (picture 1), bacteria do not appear to accompany the irrigation fluid into adjacent tissues in animal studies [15], so the risk of transmitting infection through irrigation is likely low [16].
Debridement — Surgical debridement is the most appropriate choice for removing large areas of necrotic tissue and is indicated whenever there is any evidence of infection (cellulitis, sepsis). Serial surgical debridement in a clinical setting, when appropriate, appears to be associated with an increased likelihood of healing [17,18]. Alternative forms of debridement (eg, enzymatic, biologic) may be used for smaller acute wounds if surgical debridement is not available.
Surgical debridement — Sharp excisional debridement uses a scalpel or other sharp instruments (eg, scissors, tissue nipper, curette) to remove devitalized tissue and accumulated debris, including biofilm. Sharp excisional debridement decreases bacterial load and stimulates deficit contraction and wound epithelialization [19].
Bleeding from the surface of the wound commonly occurs during debridement. Bleeding can occur from the healing surfaces or from the deep layers of the skin at the wound edge. The propensity for a wound to bleed depends upon the type of wound, the stage of wound healing, and its location.
Bleeding impairs the ability to see what tissue should be debrided, so if bleeding occurs after a dressing is removed, hemostasis should be achieved before commencing debridement. Diffuse bleeding from healing surfaces is managed with gentle pressure. Once the bleeding stops, debridement can continue. Bleeding from skin from a subdermal vessel can be coagulated (electrocautery, a silver nitrate stick), and then debridement can continue.
Alternative methods — When equipment and personnel are not available for surgical debridement or surgical debridement cannot be performed safely (eg, patients who are not surgical candidates, pain control would be inadequate), alternative methods including enzymatic debridement or biologic debridement may be used provided there is no evidence of infection. These methods are more typically used in conjunction with chronic wound management but may occasionally be used to manage acute wounds.
Enzymatic — Enzymatic debridement involves applying exogenous agents to the wound. Many products are commercially available (table 2), but the results of clinical studies do not demonstrate the superiority of any specific agent, and their specific effects remain unclear [20]. Ulcer healing rates are not improved with the use of most topical agents, including debriding enzymes [20]. However, collagenase may promote endothelial cell and keratinocyte migration, thereby stimulating angiogenesis and epithelialization as its mechanism of action rather than functioning as a strict debridement agent [21]. It also remains a good option for patients who require debridement but are not surgical candidates.
Biologic — An additional method of wound debridement uses the larvae of the Australian sheep blowfly (Lucilia [Phaenicia] cuprina) or green bottle fly (Lucilia [Phaenicia] sericata, medical maggots) [22,23]. The larvae secrete proteolytic enzymes that liquefy necrotic tissue, which is subsequently ingested while leaving healthy tissue intact.
Maggot therapy has been used predominantly for a variety of wounds for the treatment of pressure ulcers [24,25], venous ulceration [26-29], diabetic foot ulcers [22,30], and also for some acute wounds [31]. Maggot therapy can be used as a bridge between debridement procedures or for wound debridement when surgical debridement is not available or cannot be performed [32]. Basic and clinical research suggests that maggot therapy may have benefits such as antimicrobial action and stimulation of wound healing [23,26,33-35]. However, randomized trials have not reported consistent reductions in the time to wound healing compared with standard wound therapy (eg, debridement, hydrogel, moist dressings) [36,37]. Maggot therapy appears to be at least equivalent to hydrogel in terms of cost [37,38].
Dressing changes include the application of a perimeter dressing and a cover dressing of mesh (chiffon) that helps direct the larvae into the wound and limits their migration (movie 1). The larvae can also be applied within a prefabricated "biobag" (picture 2), commercially available outside the United States, that facilitates application and dressing change [39-42]. Randomized trials comparing "free range" with biobag-contained larvae in the debridement of wounds have not been performed.
Larvae are generally changed every 48 to 72 hours. One study that evaluated maggot therapy in venous ulcers found no advantage to continuing maggot therapy beyond one week [27]. Patients were randomly assigned to maggot therapy (n = 58) or conventional treatment (n = 61). The difference in the slough percentage significantly increased in the maggot therapy group compared with the control groups on day 8 (67 versus 55 percent), but not at 15 or 30 days.
A main disadvantage of maggot therapy relates to negative perceptions about its use by patients and staff. One concern among patients is the possibility that the larvae can escape the dressing, although this rarely occurs. Although one study identified that approximately 50 percent of patients indicated they would prefer conventional wound therapy over maggot therapy, 89 percent of the patients randomly assigned to maggot therapy said they would undergo larval treatment again [43]. Perceived pain or discomfort with the dressings associated with maggot therapy may limit its use in approximately 20 percent of patients [44].
Topical therapy — Topical agents such as antiseptics and antimicrobial agents (table 3) are not typically needed to manage acute wounds but may be used to control locally heavy contamination (eg, burn wounds). (See "Topical agents and dressings for local burn wound care", section on 'Colonized/contaminated/infected burn wounds'.)
WOUND PACKING —
Wounds with large soft-tissue defects may have an area of dead space between the surface of intact healthy skin and the wound base. Wounds are described as tunneled or undermined if the defect involves the wound base and edges.
Although there have been no specific trials comparing packed versus unpacked wounds, wound packing is considered basic standard care. When packing wounds is associated with significant dead space or undermining, it is important to reduce physiologic dead space, absorb exudate/seroma collection, and reduce the potential for infection. Packing can also be an effective temporary dressing technique between planned serial debridement [45,46].
A traditional gauze dressing is often used to pack wounds to aid with ongoing debridement of devitalized tissue from the wound bed. The gauze is moistened with normal saline or tap water and placed into the wound and covered with dry layers of gauze. As the moistened gauze dries, it adheres to surface tissues, which are then removed when the dressing is changed. Dressing changes should be frequent enough that the gauze does not dry out completely, which may be up to two to three times daily. A disadvantage of gauze dressings is that they can also remove developing granulation tissue, resulting in re-injury. Thus, these dressings are discontinued when all the necrotic tissue has been removed, and granulation tissue becomes present. An alternative to gauze dressing for managing wounds with significant dead space is negative pressure wound therapy. (See 'Negative pressure wound therapy' below.)
Many of the materials that are used as topical dressings for wounds (ie, foams, alginates, hydrogels) can also be molded into the shape of the wound and can be useful for wound packing. As with their use as wound dressings, there is little consensus over what constitutes the best material for wound packing. (See 'Wound dressings' below.)
Wound dressing changes associated with large tissue defects can be managed without repeated applications of tape to the skin by using Montgomery straps (picture 3).
WOUND DRESSINGS —
When a suitable dressing is applied to a wound and changed appropriately, the dressing can arguably have a significant impact on the speed of wound healing, wound strength, the function of the repaired skin, and the cosmetic appearance of the resulting scar.
An ideal dressing is one that has the following characteristics:
●Absorbs excessive wound fluid while maintaining a moist environment
●Protects the wound from further mechanical or caustic damage
●Prevents bacterial invasion or proliferation
●Conforms to the wound shape and eliminates dead space
●Debrides necrotic tissue
●Does not macerate the surrounding viable tissue
●Achieves hemostasis and minimizes edema through compression
●Does not shed fibers or compounds that could cause a foreign body or hypersensitivity reaction
●Eliminates pain during and between dressing changes
●Minimizes dressing changes
●Is inexpensive, readily available, and has a long shelf life
●Is transparent to monitor wound appearance without disrupting the dressing
In most cases, a dressing with all of the listed characteristics is not available, and no single dressing is perfect for all wounds. The clinician should evaluate individual wounds and decide which characteristics are most important in the case of a particular wound and choose the best dressing on a case-by-case basis. A detailed description of common, differing types of wounds and potential dressings is given in the tables (table 4 and table 5). The wound must be continually monitored as its characteristics and dressing requirements will change over time [47].
There is little clinical evidence to aid in the choice between the different types of wound dressings. Consensus opinion supports the following general principles for chronic wound management [48], but similar principles may be used for acute wound management:
●Hydrogels for the debridement stage
●Low-adherent dressings that maintain moisture balance for the granulation stage
●Low-adherent dressings for the epithelialization stage
For acute wound dressing selection, the degree of drainage/moisture should help guide the clinician. A relatively moist wound bed is clearly beneficial for healing, while excessive moisture is detrimental, leading to maceration. The ideal dressing for a given wound would wick away excess drainage while maintaining an appropriate level of moisture. Although some dressings may have additional benefits in terms of local antimicrobial effects, reduced pain on change, odor control, and anti-inflammatory or mild debridement ability, these are secondary benefits [49].
Dressings are typically changed once a day or every other day to avoid disturbing the wound-healing environment. Because some dressings may impede some aspects of wound healing, they should be used with caution. For example, alginate dressings with high calcium content may impede epithelialization by triggering premature terminal differentiation of keratinocytes [48], and highly silver-containing dressings are potentially cytotoxic and should not be used in the absence of significant infection.
Importance of moisture — For much of the history of medicine, it was believed that wounds should be left exposed to the air. However, an important study in an animal model showed that moist wounds healed more rapidly compared with wounds that dried out [50]. Similar results have been observed in humans [51-53]. The moisture content of a wound bed must be kept in balance. The area should be moist enough to promote healing, but excess exudate must be absorbed away from the wound to prevent maceration of the healthy tissue.
Occluded wounds heal up to 40 percent more rapidly than non-occluded wounds [51]. This is thought to be due, in part, to the easier migration of epidermal cells in the moist environment created by the dressing [52]. Another mechanism for improved wound healing may be the exposure of the wound to its own fluid [54]. Acute wound fluid is rich in platelet-derived growth factor basic fibroblast growth factor, and has a balance of metalloproteases serving a matrix custodial function [55]. These interact with one another and with other cytokines to stimulate healing [56]. (See "Basic principles of wound healing", section on 'Wound healing'.)
In addition to faster wound healing, wounds treated with occlusive dressings are associated with less prominent scar formation [57]. One study of porcine skin found an acceleration in the inflammatory and proliferative phases of healing when wounds were covered with an occlusive dressing as opposed to dry gauze [58]. This "acceleration" through the wound phases may prevent the development of a chronic wound state, which is typically arrested in the inflammatory phase of healing. Wounds with greater amounts of inflammation tend to result in more significant scars, and thus, the decreased inflammation and proliferation seen with wound occlusion may also decrease the appearance of the scar.
Dressing types — Although dressings can be categorized based on many characteristics (table 4), it is most useful to classify dressings by their water-retaining abilities because the primary goal of a dressing is the maintenance of moisture in the wound environment. As such, dressings are classified as open, semi-open, or semi-occlusive.
Open — Open dressings primarily include gauze, which is typically moistened with saline before being placed into the wound. Gauze bandages are available in multiple sizes, including 2 x 2 inch and 4 x 4 inch square dressings and in 3 or 4 inch rolls. Thicker absorbent pads are used to cover the gauze dressings. For managing large wounds, self-adhesive straps can be used to hold a bulky dressing in place. As discussed above, dry gauze dressings are discouraged. Wet-to-moist gauze dressings are useful for packing large soft-tissue defects until wound closure or coverage can be performed. While gauze dressings are inexpensive, they often require frequent dressing changes.
Semi-open — Semi-open dressings typically consist of fine mesh gauze impregnated with petroleum, paraffin wax, or other ointment and have product names such as Xeroform, Adaptic, Jelonet, and Sofra Tulle. This initial layer is covered by a secondary dressing of absorbent gauze and padding, and finally, a third layer of tape or another adhesive. The benefits of semi-open dressings include their minimal expense and ease of application. The main disadvantage of this type of dressing is that it does not maintain a moisture-rich environment or provide good exudate control. Fluid is permitted to seep through the first layer and is collected in the second layer, allowing for both desiccation of the wound bed and maceration of the surrounding tissue in contact with the secondary layer. Other disadvantages include the bulk of the dressing, its awkwardness when applied to certain areas, and the need for frequent changing.
Semi-occlusive — Semi-occlusive dressings come in a wide variety of occlusive properties, absorptive capacities, conformability, and bacteriostatic activity. Semi-occlusive dressings include films, foams, alginates, hydrocolloids, and hydrogels (table 4).
Polymer films are transparent sheets of synthetic self-adhesive dressing that are permeable to gases such as water vapor and oxygen but impermeable to larger molecules, including proteins and bacteria. This property enables insensible water loss to evaporate, but it traps wound fluid enzymes within the dressing and prevents bacterial invasion. These dressings are sometimes known as synthetic adhesive moisture vapor-permeable dressings and include Tegaderm, Cutifilm, BlisterFilm, and Bioclusive. In a review of 33 published studies, transparent film dressings provided the fastest healing rates and lowest infection rates, and they were the most cost-effective method for dressing split-thickness skin graft donor sites [59].
The advantages of these dressings include their ability to maintain moisture, encourage rapid reepithelization, and their transparency and self-adhesive properties. Disadvantages of film dressings include limited absorptive capacity, and they are not appropriate for moderate to heavily exudative wounds. If they are allowed to remain in place over a wound with heavy exudates, the surrounding skin is likely to become macerated. In addition, if the wound dries out, film dressings may adhere to the wound and be painful and damaging to remove.
Adjunctive therapies
Negative pressure wound therapy — Negative pressure wound therapy (NPWT) enhances wound healing by reducing edema surrounding the wound, stimulating circulation, providing wound contraction, and increasing the rate of granulation tissue formation [60-63]. The technique involves the application of controlled subatmospheric pressure to a wound covered with a foam dressing. (See "Negative pressure wound therapy".)
Acute wounds are often traumatic but can also be due to surgical debridement of infected or necrotic tissue. Management of necrotizing soft tissue infection requires extensive and repeated surgical debridement. The debrided regions often present a wound dressing challenge due to anatomic location (eg, Fournier gangrene), the size of the tissue defect, or the patient's body habitus. (See "Necrotizing soft tissue infections", section on 'Surgical debridement'.)
The open wound that results is often substantial. For most patients, the question is generally when, not if, their wounds will heal. The time interval required until either secondary closure can be performed or healing by secondary intention occurs is variable and depends upon the size of the defect and the patient's overall clinical status (eg, other injuries, nutrition, comorbidities).
NPWT dressings can be applied immediately following operative debridement, which simplifies postoperative wound care. The ability of the foam and adhesive dressing to conform to almost any wound contour, shape, or size contributes to the success of NPWT, as detailed in case reports, in these complex wounds [64-67]. NPWT can also be used in conjunction with skin grafts or flaps, which are frequently needed to cover tissue defects.
For acute open wounds, NPWT is associated with a reduced time to wound closure [68,69]. For example, one trial randomly assigned 54 patients with open wounds to receive either NPWT or moist saline dressings [69]. The NPWT group had healthier-appearing wounds and significantly faster reduction of the wound surface area (3.8 versus 1.7 percent per day).
NPWT has also been used to manage acute wounds resulting from lower extremity fasciotomy, degloving injury, open amputation, and complex traumatic wounds with exposed tendon, bone, or orthopedic hardware. These wounds are typically large and difficult to dress. Systematic reviews have not identified any randomized trials; however, the available observational studies suggest that NPWT is safe and has an efficacy comparable to standard dressings [70,71]. The primary clinical advantage of NPWT in the trauma population is its ease of application, decreased number of dressing changes, and reduction in the complexity of subsequent reconstructive procedures [60,72-78].
NPWT may have a particular role in the treatment of burn wounds. Impairment of blood flow in the zone of stasis may lead to burn wound progression (ie, partial-thickness burn becomes full-thickness burn). In animal models, subatmospheric pressure increases burn wound perfusion and limits this progression [79] (see "Negative pressure wound therapy", section on 'Mechanism of action'). Anecdotal case reports and small case series have reported NPWT in the treatment of acute burn wounds [80-82]. Two studies have looked at bilateral hand burns as a model: one hand is treated with conventional dressings and the other with NPWT [81,82]. A significant clinical advantage of the NPWT group was the ability to position the hand without the need for additional splinting. These preliminary studies have demonstrated the safety and feasibility of NPWT in burn patients.
NPWT has been used instead of traditional bolstering methods to provide skin graft fixation [83-85]. The NPWT dressing ultimately distributes a positive pressure uniformly over the surface of the fresh graft, immobilizing the graft with less chance of shearing [86]. Improved qualitative skin graft take, and quantitative improvements in skin graft success (eg, reduced number of repeat grafts) have been described in observational studies [72,73,87,88] and two randomized trials [89,90]. In one of the trials, 60 patients were randomly assigned to conventional bolster dressing or NPWT following split-thickness skin graft [89]. NPWT was associated with a significant reduction in the loss of graft area (0 versus 4.5 cm in the control group) and the median duration of hospitalization (13.5 versus 17 days). (See "Skin autografting", section on 'Graft immobilization'.)
Hyperbaric oxygen therapy — Hyperbaric oxygen therapy (HBOT) has positive effects on wound healing in vitro in many situations [91]. Hyperoxia induced by HBOT effectively improves endothelial progenitor cell mobilization, but therapy is not targeted to the wound site. Endothelial progenitor cells play an important role in wound healing because they participate in the formation of new blood vessels in areas of hypoxia [92]. (See "Hyperbaric oxygen therapy", section on 'Mechanisms of action'.)
Although HBOT has been used as an adjunct to wound care in the treatment of a variety of acute wounds [93-98], the specific indications are relatively unclear. Most studies are observational, and the few available trials are limited by small sample size and low quality [99-101].
●HBOT may be of value in patients with extensive soft tissue injury. A systematic review identified three trials evaluating the use of HBOT in acute surgical and traumatic wounds [102]. In one of the trials, 36 patients with crush injuries were randomly assigned to a 90-minute twice-daily HBOT or sham treatment for a total of six days postoperatively [103]. The group treated with hyperbaric oxygen had significantly more complete healing (17 versus 10 patients) and required fewer skin flaps, grafts, vascular surgery, or amputation (1 versus 6 patients). (See "Surgical management of severe lower extremity injury", section on 'Wound care and coverage' and "Patient management following extremity fasciotomy", section on 'Hyperbaric oxygen'.)
●HBOT may improve the survival of skin grafts and reconstructive flaps that have compromised blood flow, thereby preventing tissue breakdown and the development of wounds. Patients who require skin grafting or reconstructive flaps in areas with local vascular compromise, previous radiation therapy, or sites of previous graft failure may benefit from prophylactic therapy. (See "Hyperbaric oxygen therapy", section on 'Radiation injury'.)
When indicated, HBOT is accomplished in a specialized chamber that allows for patient monitoring. Chamber pressure is typically maintained between 2.5 and 3 atmospheres of pressured oxygen or air. Therapy for nonhealing wounds generally consists of daily sessions of 1.5 to 2 hours for 20 to 40 days [91]. The mechanisms and techniques of HBOT are discussed in detail elsewhere. Serious adverse events can be associated with HBOT, including seizures and pneumothorax. (See "Hyperbaric oxygen therapy" and "Hyperbaric oxygen therapy", section on 'Technique'.)
WOUND CLOSURE
Primary closure — Primary closure (sometimes referred to as closure by primary intention) refers to the relatively immediate direct apposition of skin edges of acute surgical or traumatic wounds after appropriate wound preparation and typically using sutures or staples (figure 4). (See "Minor wound evaluation and preparation for closure" and "Skin laceration repair with sutures" and "Closure of minor skin wounds with staples".)
Delayed primary closure — Primary (immediate) closure is contrasted with delayed primary closure (sometimes referred to as closure by third intention), where skin edge apposition occurs following an interval of wound management (figure 4). In other words, the wound is purposefully left open for a period, and then the edges are directly apposed with sutures and/or staples. Although delayed, this still represents primary closure as the skin edges are brought into direct apposition by external means. For abdominal wounds, chest wounds, and surgical wounds without evidence of infection, delayed closure is widely accepted (figure 4) [104].
Healing by secondary intention — Wound closure by secondary intention (figure 5) is an option for some superficial wounds (eg, pressure-induced injury, venous limb ulcer, small burn wounds). This might also include healing of a small incision used to decompress an abscess or healing of wounds from puncture wounds when there is a concern for closing over potentially infected dead space.
In these cases, the wound is purposefully left open and fills in with granulation tissue, and eventually epithelization, over time. At no point are the skin edges brought together by external means. The process of healing by secondary intention might be assisted using negative pressure wound therapy.
Closure using skin grafts or flaps
●Skin grafts – Skin grafts are used to provide coverage for larger or wider wounds without substantial depth (eg, full-thickness wound, intact fascial layer, granulation base). Skin grafts are used to prevent fluid and electrolyte loss and reduce bacterial burden and infection. Skin transplanted from one location to another on the same individual is termed an autogenous graft or autograft. Skin grafts are classified as either split-thickness or full-thickness, depending upon the amount of dermis included in the graft. The choice between full- and split-thickness skin grafting depends upon the condition of the wound, location, size, and need for cosmesis and is reviewed separately [105,106]. (See "Skin autografting".)
•A partial or split-thickness skin graft contains a variable thickness of the dermis, while a full-thickness skin graft contains the entire dermis.
•With full-thickness grafts, the characteristics of normal skin are maintained with a thicker dermal component. However, thicker grafts require a more robust wound bed due to the greater amount of tissue that needs to be revascularized.
●Skin substitutes – Skin substitutes have similar indications to skin grafts and can facilitate the healing of superficial wounds. They can be used when traditional dressings have failed or are deemed inappropriate [107]. Skin substitutes may be also used to temporize or to provide a reconstructive matrix for deeper wounds. Some skin substitutes have immune modulator activity that can help change the histologic characteristics from a proinflammatory environment to one that is proangiogenic [6,18]. (See "Skin substitutes".)
●Skin or tissue flaps – For complex or larger wounds or the loss of multiple tissue components (skin, subcutaneous tissue, muscle), a tissue flap (eg, rotation flap, Z-plasty, pedicle flap, free tissue transfer) may be required to provide adequate wound coverage. (See "Z-plasty" and "Overview of flaps for soft tissue reconstruction".)
APPROACH TO SPECIFIC ACUTE WOUNDS —
Specific strategies for wound care and the efficacy of wound management strategies for the treatment of specific wounds are discussed in individual topic reviews:
●Simple laceration – Simple traumatic lacerations may be cleaned and closed primarily with either staples, sutures, or skin adhesive. (See "Minor wound evaluation and preparation for closure" and "Skin laceration repair with sutures" and "Closure of minor skin wounds with staples" and "Minor wound repair with tissue adhesives (cyanoacrylates)".)
●Complicated laceration – Following cleansing of the wound and debridement, an attempt is often made to close more complicated lacerations (eg, stellate, contiguous, intersecting). It is not uncommon for the irregular skin edges or skin at sites where lacerations meet to break down. Debridement and the use of plastic surgery techniques may be needed to provide an acceptable cosmetic and functional result. (See "Z-plasty".)
●Large tissue defect – Large tissue defects can result from traumatic wounds or following debridement of devitalized tissue due to infection (eg, necrotizing infection) or traumatic tissue loss. Once the debridement is completed, the wound can be packed open with wet-to-moist saline gauze dressings or using negative pressure wound therapy until the wound bed allows for skin graft or other advanced biologic tissues or closure using flap reconstruction [63]. (See 'Wound packing' above and 'Wound closure' above.)
●Burns – Burn wound care depends upon many factors, including the depth of the burn and the affected anatomic location. Burn wound management is discussed separately. (See "Topical agents and dressings for local burn wound care" and "Overview of surgical procedures used in the management of burn injuries".)
●Postoperative surgical incision – Postoperative surgical incisions (clean, clean-contaminated) are typically covered with a dry dressing that is held in place with an adhesive (eg, tape, Tegaderm). The initial postoperative dressing might be removed within 48 hours, depending on the procedure and anatomic location, provided the wound has remained dry. The timing with which the patient can resume bathing/showering is not well defined and depends on the procedure [108,109].
Surgical wounds that have been opened to manage surgical site infection are typically packed open following debridement. Specific management depends on the location of the surgical site and whether prosthetic material or an implant was involved. (See "Overview of the evaluation and management of surgical site infection", section on 'Wound management'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Open wound management".)
SUMMARY AND RECOMMENDATIONS
●Acute wounds – Acute wounds (surgical, nonsurgical) occur suddenly and usually have an easily identifiable mechanism of injury leading to disruption of skin integrity. Regardless of etiology, wound healing progresses at a sustained, measurable rate through the stages of healing as expected. (See 'Wound definitions and classification' above.)
●Initial care – Wounds with devitalized tissue, contamination, or residual foreign material (eg, sutures, glass) benefit from cleaning and debridement prior to further wound management. (See 'Initial care' above.)
•Irrigation – Irrigation with saline or water is important for cleansing the wound to reduce bacterial load and remove loose material. The act of irrigation and the volume of irrigant probably provide the primary positive benefits. There are no high-quality data to support the use of any additive to the irrigant, or any particular additive. (See 'Irrigation' above.)
•Debridement – We suggest sharp surgical debridement over nonsurgical methods for the initial debridement of devitalized tissue when feasible (Grade 2C). Alternatives (enzymatic, biologic) may occasionally be used if surgical debridement cannot be accomplished. (See 'Initial care' above and "Overview of treatment of chronic wounds", section on 'Surgical debridement'.)
•Topical therapy – Topical agents such as antiseptics and antimicrobial agents are not typically needed to manage acute wounds but may be used to control locally heavy contamination.
●Wound dressings and adjuncts – Wound dressings are chosen based on their ability to manage dead space, control exudate, reduce pain during dressing changes (as applicable), prevent bacterial overgrowth, and ensure proper fluid balance. They should also be cost efficient and manageable for the patient and caregivers or nursing staff. (See 'Wound dressings' above.)
•Negative pressure wound therapy – For complex or deep wounds, negative pressure wound therapy (NPWT) may protect the wound and reduce the complexity and depth of the defect. NPWT is frequently used to manage complex wounds prior to definitive closure. (See 'Negative pressure wound therapy' above.)
•Hyperbaric oxygen therapy – Hyperbaric oxygen therapy (HBOT) has been used to stimulate healing in a variety of acute wounds (eg, traumatic wounds, tissue flap grafts), but specific indications remain unclear. (See 'Hyperbaric oxygen therapy' above.)
●Wound closure – Following wound bed preparation, acute wounds can often be closed primarily but may require delayed closure or healing by secondary intention. Larger wounds may require a skin graft or flap closure to achieve coverage. (See 'Wound closure' above.)
