Wound Care & Minor Procedures

How the injury happened tells us most of what we need to know. A clean slice from a kitchen knife is a completely different problem from a crush injury from machinery, which is different again from a puncture from a rusty nail, a bite, a high-pressure injection injury, or a graze from falling off a motorcycle onto tarmac. The mechanism predicts the contamination, the depth, the damage to tissue you cannot see, and the infection risk.

Time matters. A wound seen within a few hours of injury has options that a wound seen two days later does not, because bacterial contamination becomes established infection with time. If you are going to come, come early.

We examine the wound for depth and for what lies beneath it, and this is the part that gets skipped in self-treatment. A cut on the hand that looks trivial can have divided a tendon or a nerve, and the way to know is to test movement and sensation beyond the wound before it is closed. A wound over a joint may have entered the joint. A wound on the scalp or over a bone can be deeper than it appears. We check circulation and sensation past the injury every time.

Contamination and foreign material are looked for actively. Grit, glass, wood splinters, metal fragments and clothing fibres left inside a wound guarantee infection and delayed healing, and glass and metal in particular are frequently missed because the entry point looks small. Where a radio-opaque foreign body is suspected, we have X-ray on site.

We also assess you, not just the wound. Diabetes, peripheral vascular disease, immunosuppression, steroid use, smoking, poor nutrition and older age all impair healing and raise infection risk, and they change the plan — closer follow-up, a lower threshold for antibiotics, sometimes referral where a healthy person would simply be dressed and sent home. And at every wound visit we ask about tetanus immunisation, which has its own section below because it is the single most forgotten element of wound care.

Closing a wound brings the edges together so it heals faster, with a neater scar and less risk of the edges pulling apart. It is appropriate for clean wounds, seen early, where the edges gape, on parts of the body under tension or where cosmetic outcome matters — particularly the face.

There is a time window. Suturing is generally most appropriate within several hours of injury, and the acceptable interval is shorter for contaminated wounds and somewhat longer for very clean wounds on well-supplied areas such as the face. Beyond that window, closing a wound traps bacteria inside it and converts a manageable contaminated wound into an abscess. This is the single most important reason to come early rather than deciding at midnight that tomorrow will do.

Wounds we generally do not close include puncture wounds, which are deep and narrow with contamination driven inwards and no way to clean the bottom; most bite wounds, for the same reason; heavily contaminated wounds full of grit or organic material; wounds already showing signs of infection; and old wounds outside the window. These are cleaned thoroughly, dressed open, reviewed, and where appropriate closed later once it is clear that infection has not developed. Leaving a wound open is not a failure to treat it — it is often the treatment.

Tissue glue is an excellent alternative for the right wound: clean, straight, low tension, edges that come together easily, and no need for deep sutures. It avoids needles entirely, which makes it particularly good for children. It is not suitable for wounds over joints or on the hands where movement pulls at the edges, for gaping wounds, for wounds inside the mouth or near the eye, or for anything contaminated.

Some wounds should not be closed here at all, but referred. Wounds with tendon, nerve, artery or joint involvement need surgical assessment. Deep hand wounds need care from someone who works on hands, because the functional cost of getting a hand wrong is high and permanent. Facial wounds involving the eyelid margin, the lip border or the ear cartilage need precise repair. Wounds with significant tissue loss, open fractures, and any wound where the bone is visible go to hospital. We will tell you honestly when that is the case and send you with the wound properly cleaned and dressed rather than delaying you.

Aftercare for a sutured wound: keep it clean and dry for the first day or two, then follow the instructions you are given about washing. Do not soak it, do not swim, and do not pick at it. Suture removal timing varies by site because the tension and blood supply differ — face sutures come out early to avoid marks, sutures on the back, over joints and on the lower leg stay in considerably longer. We will tell you the date. Removing sutures too early risks the wound opening; leaving them too long leaves stitch marks.

Scarring is worth being honest about. Every wound that goes through the full thickness of the skin leaves a scar, and no technique prevents that. What good closure, avoiding infection, and protecting the healing scar from sun exposure for several months do is make the scar as inconspicuous as it can be. Some people, particularly with darker skin, form keloid or hypertrophic scars, and if that has happened to you before, tell us at the start.

Some redness and mild discomfort around a fresh wound in the first day or two is normal inflammation and part of healing. What is not normal is redness and pain that are increasing rather than settling after the first couple of days.

The signs of an infected wound are increasing pain rather than decreasing pain, spreading redness around the wound, swelling, heat, pus or cloudy discharge, an unpleasant smell, a wound that was closing and has started to open again, and feeling unwell or feverish. Any of those means come in, and come the same day rather than adding another home dressing.

Cellulitis is infection spreading through the skin and the tissue beneath it, and it looks like an expanding area of red, hot, tender, swollen skin, often with a poorly defined edge. It is frequently accompanied by fever and feeling generally unwell. It needs antibiotics, and it needs them promptly, because untreated cellulitis can spread rapidly and can seed infection into the bloodstream. A practical tip we give patients: mark the edge of the redness with a pen and note the time. If the redness has moved beyond the mark, the infection is winning and you need to be seen again urgently.

Red streaks running up a limb from a wound towards the body indicate infection tracking along the lymphatic channels. That is a sign to be seen immediately, not tomorrow.

Certain groups need a much lower threshold: people with diabetes, anyone immunosuppressed, people on chemotherapy or long-term steroids, those with poor circulation, and the very young and very old. In these patients infection progresses faster, causes fewer of the usual warning signs, and does more damage.

First aid comes before anything else and it makes a real difference to the final depth of the burn. Stop the burning process, remove clothing and jewellery from the area unless it is stuck to the skin, and cool the burn under cool running water for around twenty minutes. This is worth doing even up to a few hours after the injury. Do not use ice, which causes further damage. Do not apply toothpaste, soy sauce, oil, butter, ash, kicap or any traditional preparation — these are common in Malaysia, they do not help, they trap heat, they introduce infection and they make the burn far harder to assess and clean. Cover loosely with cling film or a clean non-fluffy cloth and come in. Keep the person warm overall while cooling the burn, particularly with children.

Depth determines how a burn heals. A superficial burn involves only the outer layer, is red, dry and painful, blanches when pressed, and heals within about a week without scarring — ordinary sunburn is the familiar example. A partial thickness burn extends into the dermis; it blisters, is moist, and is typically very painful because nerve endings are exposed and irritated. Superficial partial thickness burns generally heal within two to three weeks with good care; deeper partial thickness burns take longer and tend to scar. A full thickness burn destroys the entire skin including the nerve endings, so it may be painless in the centre, and appears white, waxy, leathery, brown or charred, and does not blanch. It will not heal from the edges alone if it is more than very small, and it requires surgical management.

Extent matters as much as depth, because a large burn causes fluid loss and systemic effects beyond the skin. A rough guide for small burns is that the patient's own palm including the fingers is approximately one percent of their body surface. Larger burns are estimated in hospital using proper charts.

Certain burns go to hospital regardless of how they look. Burns to the face, eyes, ears, hands, feet, genitals or across a major joint, because of the functional and cosmetic consequences. Circumferential burns encircling a limb or the chest, which can constrict as they swell. Any full thickness burn. Large partial thickness burns. Electrical burns, which cause damage along the path of the current that is invisible at the skin and which can affect the heart. Chemical burns, which continue to damage until the chemical is removed — irrigate with copious water and bring the chemical name or safety data sheet with you. Any burn with suspected inhalation injury, indicated by burns around the mouth and nose, singed nasal hairs, a hoarse voice, soot in the sputum, coughing or breathlessness, which is a genuine emergency because the airway can swell shut. Burns in infants and the elderly. And any burn where the explanation does not fit the injury.

What we manage here: smaller superficial and partial thickness burns, in appropriate sites, in patients who can be reviewed. That means cleaning, careful assessment of depth, decisions about blisters, an appropriate dressing, pain relief, tetanus assessment, and review — because burns are dynamic and a burn that looks superficial on day one can declare itself deeper on day three. We would rather see you again than assume the first assessment was final.

An abscess is a walled-off collection of pus. It presents as a painful, red, hot, swollen lump that becomes increasingly tender, often with a throbbing pain that disturbs sleep, and sometimes with fever. Common sites are the armpit, the groin, the buttock, the back of the neck, around the nail fold, and at the base of the spine.

The single most important thing to understand about an abscess is that antibiotics alone usually will not cure it. The pus is enclosed within a wall of inflamed tissue with a poor blood supply, and antibiotics reach it badly. Pus needs to come out. This is one of the oldest principles in surgery and it has not changed.

Incision and drainage is done under local anaesthetic. The area is numbed, an incision is made, the pus is drained, any internal partitions within the cavity are broken down so it drains completely, and the cavity is washed out. One point worth explaining in advance: local anaesthetic works less well in infected, acidic tissue than in normal tissue, so the procedure can still be uncomfortable despite adequate anaesthetic. We will tell you honestly what to expect rather than promising it will be painless. The relief afterwards is usually immediate and substantial, because the pressure is what was causing the pain.

The cavity is often packed with a dressing rather than closed. This keeps the opening from sealing over prematurely, which would simply allow the pus to reaccumulate, and allows the cavity to heal from the base upwards. Packing is changed at intervals and gradually reduced, so you will need follow-up visits. Follow-up consultations here are free.

Antibiotics are used alongside drainage in specific circumstances: significant surrounding cellulitis, fever or systemic illness, diabetes or immunosuppression, and abscesses in certain locations such as the face. They complement drainage; they do not replace it.

Some abscesses are referred rather than drained here — large or deep collections, abscesses close to important structures, perianal abscesses which frequently have a deeper component, abscesses in the very unwell, and those in the central face where the venous drainage carries particular risk.

Recurrent abscesses deserve a look at the reason. Undiagnosed diabetes is a classic cause and worth excluding. Recurrent abscesses in the armpits, groin and under the breasts may be hidradenitis suppurativa, which is a chronic skin condition requiring a different long-term approach rather than repeated drainage. A recurring lump at the top of the buttock cleft is usually a pilonidal sinus, which needs definitive surgical treatment to stop recurring.