Previous changes

April 2021 — minor update. The definition of incision has been clarified. 

January 2021 — minor update. The contraindications and drug interactions for erythromycin have been updated in line with a drug safety update issued by the Medicines and Healthcare products Regulatory Agency (MHRA). 

October 2018 — minor update. The section on the adverse effects of metronidazole has been updated. 

June 2017 — reviewed. A literature search was conducted in May 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. No major changes to recommendations have been made.

July 2015 — minor update. Links to the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues have been added to the section on Prescribing information.

February 2013 — minor update. The 2013 quality, innovation, productivity and prevention (QIPP) options for local implementation have been added to this topic. 

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.   

August 2012 — reviewed. A literature search was conducted in August 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made.

July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the MHRA. Prescriptions have been updated to reflect the revised dosing. 

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

October 2010 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

August 2009 — minor update. Advice from the National Institute for Health and Care Excellence (NICE) guideline on when to suspect child maltreatment has been added to this topic. 

July to October 2007 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. More detailed information has been included on how to assess and manage a laceration at high risk of infection.

October 2006 — minor update. Analgesia prescriptions have been updated because new doses of ibuprofen for children are recommend in the British National Formulary (BNF). 

November 2005 — minor technical update. 

July 2005 — minor correction to reference list. 

September 2004 — updated to include the new combined tetanus vaccines Pediacel®, Repevax®, and Revaxis®. 

March 2004 — reviewed. Validated in May 2004 and issued in July 2004.

May 2001 — reviewed. Validated in July 2001 and issued in October 2001.

August 1998 — written.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 November 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 November 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 November 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analyses published since 1 November 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 November 2022.

New policies

No new national policies or guidelines since 1 November 2022.

New safety alerts

No new safety alerts since 1 November 2022.

Changes in product availability

No changes in product availability since 1 November 2022.

Basis for recommendation

History and assessment

• These recommendations are based on expert opinion in the Royal Children's Hospital (RCH) Melbourne guideline Lacerations [RCH, 2022], review articles [García-Gubern, 2010; Mankowitz, 2017; Turner, 2019a], and a textbook [Newman, 2022].

Risk factors for infection

• Evidence from a cross-sectional study of people with traumatic lacerations showed that an increased likelihood of wound infection was associated with age, history of diabetes, laceration width, and the presence of a foreign body in the wound. Laceration location on the head/neck was associated with a decreased risk of infection [Hollander et al, 2001].
• Evidence from a prospective study of people with traumatic lacerations showed that diabetes, wound contamination, wound length greater than 5 cm, and location on the lower extremity were important risk factors for wound infection [Quinn, 2014]. 
• A review article defines high-risk wounds as those with comorbidities, gross contamination, involvement of deeper structures, and stellate shape [Mankowitz, 2017].  

Presentation more than 6 hours after injury 

• It has been previously suggested that there is a 'golden period' beyond which lacerations are at higher risk of infection [Forsch, 2017,; Turner, 2019a]. However, studies have confirmed that delays in wound closure rarely confer increased rates of infection; although, comorbidities such as diabetes, HIV infection, and cancer, should be considered [Mankowitz, 2017]. 
  • In a prospective study of people with traumatic lacerations, the median wound closure time for the lacerations in the wound infection group was statistically significantly longer than in the non-infection group. However, the authors acknowledged that the study had several limitations (including the small sample size and various confounding factors), and concluded that further large-scale prospective studies are needed to confirm the relationship between wound infection and time of repair [Waseem, 2012].
  • A Cochrane systematic review found no systematic evidence to guide clinical decision‐making regarding the timing of closure of traumatic wounds [Eliya-Masam, 2013].
  • In a second prospective study of people with traumatic lacerations, there were no differences in the infection rates for lacerations closed before or after 12 hours [Quinn, 2014]. 

When to suspect child maltreatment

• These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2017].

How should I manage a person with a laceration?

• If the wound is at low risk of infection and there is no need for admission or referral:
  • Clean the wound.
  • Close the wound.
  • Dress the wound.
  • Consider the need for tetanus prophylaxis for susceptible wounds, such as those exposed to soil or other external contaminants.
  • Provide verbal and written advice on wound management, including advice on wound closure removal.
• If the laceration is infected or at high risk of infection, and there is no need for admission or referral:
  
  • Clean the wound.
  • Initially, dress but do not close the wound.
  • Consider the need for antibiotics. Take a swab of the wound before starting antibiotic treatment.
  • Consider the need for tetanus prophylaxis for susceptible wounds, such as those exposed to soil or other external contaminants.
  • Provide verbal and written advice on wound management.
  • Review the person 2–5 days after the initial presentation:
    
    • If there are signs of infection and the person has not received antibiotic treatment, prescribe empirical antibiotics and arrange a further review. Take a swab of the wound before starting antibiotic treatment.
    • If there are signs of infection despite empirical antibiotics, review the swab results, change the antibiotics if indicated, and arrange further review. 
    • If there are no signs of an infection, close the wound and advise on wound closure removal.

When should I admit or refer a person with a laceration?

• Admit to hospital if:
  • The person has a severe infection or is systemically unwell. 
  • The person has signs or symptoms of tetanus infection (generalized rigidity and spasm of skeletal muscles, including lockjaw). 
• Refer to A&E if:
  • The expertise to manage the wound is not available in primary care.
  • There is vascular damage, characterized by arterial bleeding from the wound, loss of pulse, or poor perfusion distal to the injury.
  • There is nerve damage, characterized by loss of light touch or motor function distal to the injury.
  • There is injury to a tendon, including injury to the sheath.
  • There is a bony injury or fracture. 
  • It is a facial laceration for which a good cosmetic repair is important, particularly a laceration that crosses the margins of the lips, nose, or ears.
  • It is a laceration of the palm of the hand with any signs of infection.
  • The laceration is associated with cellulitis over a joint.
  • The laceration is complex, widely gaping, or extensively devitalized.
  • There is significant contamination of tissues.
  • There is a possible foreign body remaining in the wound after cleaning, including all injuries caused by glass.
  • There is significant tissue loss or inability to primarily close wound edges.
  • The person has a high-risk tetanus-prone wound and human tetanus immunoglobulin is not available in primary care.
  • Local anaesthesia is unsuitable, for example, in children and people with needle phobia, or if there is a need for extensive wound exploration or debridement.

How should I clean the wound?

These recommendations are intended as a brief guide, as lacerations should be managed by a professional with experience in wound management. If the expertise is not available in primary care, the person should be referred to A&E.

• Disinfect the surrounding skin with an antiseptic. Avoid getting antiseptic into the wound.
• Keep hair out of the wound. If necessary, clip the hair around the wound with scissors (rather than shaving). Apply simple ointment to flatten any remaining hair away from the wound.
• Debride devitalized tissue, and pick out as much foreign material as possible.  
  • When debriding or exploring the wound, anaesthetize the area. The pain associated with the injection can be reduced by:
    • Using a 25–gauge needle.
    • Warming the anaesthetic to body temperature before use.
    • Injecting through the cut edge of the wound (rather than through a new puncture). 
    • Infusing the anaesthetic slowly.
    • Using a topical anaesthetic (such as EMLA cream) before infiltration with a local anaesthetic.   
• Irrigate the wound with potable water, cooled boiled water, or normal saline.
  • For lacerations that are not visibly contaminated, low-pressure irrigation using a syringe is sufficient.
  • For lacerations that are visibly contaminated, irrigate at high pressure with a syringe and a green needle to remove visible debris from the wound.
• Refer for radiography if there is a possible foreign body remaining in the wound after cleaning, including all injuries caused by glass.

How should I close the wound?

These recommendations are intended as a brief guide, as lacerations should be managed by a professional with experience in wound management. If the expertise is not available in primary care, the person should be referred to A&E.

• Determine an appropriate method of wound closure.
  • For clean, non-infected wounds, immediate (primary) closure (with a meticulous approximation of wound edges) is recommended. The wound edges are brought and kept together by sutures, staples, tissue adhesives, or skin closure strips.
  • For infected wounds or wounds with a high risk of infection, the wound should be cleaned and dressed, and then observed for 2–5 days to ensure no infection is apparent before it is closed (delayed primary closure).
  • For chronic wounds or wounds in which the edges cannot be approximated, the wound should be allowed to heal naturally with no attempts to aid wound closure (secondary closure). Leaving the wound open allows granulation tissue to form contraction of the wound edges and eventual epithelialization. 
• Sutures are used to close wounds. 
  • Suturing is preferred for wounds longer than 5 cm, or those 5 cm or shorter when the wound:
    
    • Requires careful approximation, for example, lacerations that cross skin tension lines or span delicate structures (such as the eyebrow or vermillion border).
    • Is subject to excessive flexing and tension (such as over joints or thick dermis), or excessive wetting.
  • There are two main types of sutures:
    • Absorbable sutures are made from either natural mammalian collagen or synthetic polymers. They break down in the body and do not require removal.
    • Nonabsorbable sutures are made from synthetic materials, such as nylon, polybutester, polypropylene, or natural silk, and require removal after placement. 
  • The choice of suture technique will depend on the type of wound, depth, degree of tension, and desired cosmetic results. As a guide:
    • Simple interrupted sutures can be used for most wounds. The use of separate stitches allows for a better approximation of the skin and fascia, resulting in more cosmetically appealing results. 
    • Simple running sutures are the best choice for long wounds with minimal tension, or for rapid hemorrhage control. They are fast and effective; however, all sutures are lost if one suture is cut by mistake or removed for drainage.
    • Mattress sutures are appropriate for deeper wounds. The deeper penetration into skin layers minimizes tension and allows for better closure at the wound edges. They can be applied vertically or horizontally.
  • Suturing should be done under local anaesthetic. The pain associated with the injection can be reduced by:
    • Using a 25–gauge needle.
    • Warming the anaesthetic to body temperature before use.
    • Injecting through the cut edge of the wound (rather than through a new puncture). 
    • Infusing the anaesthetic slowly.
    • Using a topical anaesthetic (such as EMLA cream) before infiltration with a local anaesthetic. 
• Surgical staples are alternatives to sutures and are useful for linear lacerations on the scalp or extremities. 
  • They are fast, create loose closure, allow for drainage, and can be used for unclean wounds.
  • However, they produce a poorer cosmetic result than other methods of closure and should be avoided if cosmetic outcome is important.
• Tissue adhesives (or glues) are liquid cyanoacrylate monomers that polymerize into long solid chains upon contact with blood or a wound surface, thereby holding wound edges together.
  • They can be used to close wounds that:
    • Are small (5 cm or shorter), clean, and non-infected.
    • Have edges that are easily apposed without leaving any dead space.
    • Are not subject to excessive flexing, tension, or wetting.
    • Are not in a hair-bearing area, unless hair apposition technique is being used.
    • Are not a result of mammalian bite.
• Adhesive skin-closure strips are sterile strips that are used for wound closure.
  • Skin closure strips can be effective for closing small, simple lacerations in low-tension areas with well-approximated edges; however, their lack of tensile strength can lead to wound dehiscence.
  • They are more commonly useful in achieving initial wound edge approximation, to be followed by definitive fixation with a tissue adhesive.

How should wound closure be removed?

These recommendations are intended as a brief guide, as lacerations should be managed by a professional with experience in wound management. If the expertise is not available in primary care, the person should be referred to A&E.

• For lacerations closed with nonabsorbable (non-dissolvable) sutures, arrange a follow-up appointment to remove the sutures.
  • Nonabsorbable sutures should be removed within 14 days of placement, depending on the depth and location of the wound, and the degree of tension the wound was closed under. As a general guide:
    • Sutures on the head and neck are usually removed 5–7 days after placement.
    • Sutures on the trunk or extremities are usually removed 10–14 days after placement.
    • Sutures in wounds under greater tension may have to be left in place slightly longer (up to 21 days or longer).
• For lacerations closed with absorbable (dissolvable) sutures, advise that:
  • Absorbable sutures break down in the body and do not require removal.
  • The time it takes for the sutures to disappear can vary: most types should start to dissolve or fall out within 7–14 days; however, some may take weeks or months before they disappear completely.
• For lacerations closed with staples, arrange a follow-up appointment to remove the staples.
  • Surgical staples should be removed within 14 days of placement, depending on the depth and location of the wound, and the degree of tension the wound was closed under. As a general guide:
    • Staples on the head and neck are usually removed 5–7 days after placement.
    • Staples on the trunk or extremities are usually removed 10–14 days after placement.
    • Staples in wounds under greater tension may have to be left in place slightly longer (up to 21 days or longer).
• For lacerations closed with tissue adhesives, advise the person that:
  • The glue will peel off in 5–8 days.
  • An antibiotic ointment, acetone, or petroleum jelly can help facilitate the removal.
• For lacerations closed with adhesive strips, advise the person that:
  • The adhesive strips need to stay in place for 5–7 days to allow the wound to heal.
  • To remove the strips, they should begin at one end of the incision and gently peel the skin closure off toward the other end of the incision. If any adhesive residue remains on the skin, it can be gently removed with baby oil, lotion, or medical adhesive remover.

How should I dress the wound?

These recommendations are intended as a brief guide, as lacerations should be managed by a professional with experience in wound management. If the expertise is not available in primary care, the person should be referred to A&E.

• The choice of wound dressing will depend on the type of wound and the stage of the healing process, patient preference or tolerance, site of the wound, and cost.  
  • See the British National Formulary (BNF) for suggestions on choices of dressings for different types of wounds.
  • As a general guide:
    • Non-absorbent, low-adherence dressings are suitable for clean, granulating, lightly exuding wounds without necrosis. They are placed directly on the wound bed, and protect the wound bed from direct contact with secondary dressings. 
    • Perforated film absorbent dressings are suitable only for wounds with mild to moderate amounts of exudate. Dressings with an absorbent cellulose or polymer wadding layer are suitable for use on moderately to heavily exuding wounds.
    • Advanced wound dressings are designed to control the environment for wound healing, for example, to donate fluid (hydrogels), maintain hydration (hydrocolloids), or absorb wound exudate (alginates and foams).
    • Hydrogel, hydrocolloid, and medical grade honey dressings can be used to deslough wounds by promoting autolytic debridement.
    • Sterile larvae (maggots) are also available for biosurgical removal of wound debris.

How should I manage an infected laceration?

• If there are no signs of infection, but the laceration is at high risk of infection:
  • Consider the need for prophylactic antibiotic treatment.
    • If antibiotic treatment is indicated, see the CKS topic on Cellulitis - acute for detailed information on antibiotic choices.
    • Take a swab of the wound before starting antibiotic treatment. 
  • Review the person 2–5 days after the initial presentation:
    
    • If there are signs of infection and the person did not receive prophylactic antibiotics, prescribe antibiotic treatment and arrange a further review. Take a swab of the wound before starting antibiotic treatment.
    • If there are signs of infection despite initial antibiotic treatment, review the swab results, change the antibiotics if indicated, and arrange further review. 
• If there are signs of infection and admission or referral is not indicated:
  • Prescribe empirical oral antibiotics.
    • See the CKS topic on Cellulitis - acute for detailed information on antibiotic choices.
    • Take a swab of the wound before starting antibiotic treatment. 
  • Review the person 2–5 days after the initial presentation. 
    • If signs of infection persist, review the swab results, change the antibiotics if indicated, and arrange a further review. 

When should I offer tetanus prophylaxis to a person with a laceration?

• Check the tetanus immunization status of the person with a laceration. A fully immunized person will have had a primary course of three tetanus vaccines, followed by two boosters spaced 10 years apart. For further details, see the CKS topic on Immunizations - childhood.
  • For children under 5 years who have received an adequate priming course of tetanus vaccine (at least 3 doses):
    • A tetanus vaccine is not required.
    • Continue with the recommended vaccination schedule, to ensure future immunity.
  • For children aged 5–10 years who have received an adequate priming course of tetanus vaccine (at least 3 doses) and preschool booster:
    • A tetanus vaccine is not required.
    • Continue with the recommended vaccination schedule, to ensure future immunity.
  • For children aged 5–10 years who have received an adequate priming course of tetanus vaccine (at least 3 doses) but no preschool booster:
    • For a clean wound, a tetanus vaccine is not required.
    • For a tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine.
    • For a high-risk tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine plus one dose of human tetanus immunoglobulin (HTIG) in a different site. If HTIG is not available in primary care, refer the person to the A&E department. Human normal immunoglobulin (HNIG) may be used as an alternative to HTIG.
    • Continue with the recommended vaccination schedule, to ensure future immunity.
  • For people aged 11 years and over who have received an adequate priming course of tetanus vaccine (at least 3 doses) with the last dose within 10 years:
    • A tetanus vaccine is not required.
    • Continue with the recommended vaccination schedule, to ensure future immunity.
  • For people aged 11 years and over who have received an adequate priming course of tetanus vaccine (at least 3 doses) but the last dose was more than 10 years ago:
    • For a clean wound, a tetanus vaccine is not required.
    • For a tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine.
    • For a high-risk tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine plus one dose of HTIG in a different site. If HTIG is not available in primary care, refer the person to the A&E department. HNIG may be used as an alternative to HTIG.
    • Continue with the recommended vaccination schedule, to ensure future immunity.
  • For people who have not received an adequate priming course of tetanus vaccine (at least 3 doses):
    • For a clean wound, administer an immediate reinforcing dose of the tetanus vaccine.
    • For a tetanus-prone wound or high-risk tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine plus one dose of HTIG in a different site. If HTIG is not available in primary care, refer the person to the A&E department. HNIG may be used as an alternative to HTIG.
    • Continue with the recommended vaccination schedule, to ensure future immunity.
  • If the person is not immunized or their immunization status is unknown or uncertain:
    
    • For a clean wound, administer an immediate reinforcing dose of the tetanus vaccine.
    • For a tetanus-prone wound or high-risk tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine plus one dose of HTIG in a different site. If HTIG is not available in primary care, refer the person to the A&E department. HNIG may be used as an alternative to HTIG.
    • A full course of tetanus immunization is likely to be required.
  • If the person is fully immunized but is severely immunosuppressed:
    • Consider the need for additional boosting and/or immunoglobulin as they may not be adequately protected against tetanus, despite having been fully immunized. 

What information and advice should I give a person with a laceration?

• Advise the person to:
  • Seek medical attention if they develop signs or symptoms of infection, including increasing pain, redness, or swelling spreading from the laceration; fever; or general malaise.
  • Take simple analgesia, such as paracetamol or ibuprofen, if the wound is painful or likely to become painful. 
    • For detailed prescribing information on paracetamol and ibuprofen, see the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues.
  • Keep the wound clean and dry.
    • Waterproof dressings, such as vapour-permeable dressings, allow light wetting (as from showering) without the dressing separating or the wound becoming wet.
    • Non-waterproof dressings must be protected from wetting at all times.
• After a wound has been closed, give advice on wound closure removal.